JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Baobab Psychiatric Services: New Client Intake Form
Preliminary information sheet. Please provide as much details as possible to ensure a timely processing by our intake counselors.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Services You are requesting
*
Psychiatry and Medication Management
Therapy
Spravato (Esketamine)
Full Name (Including preferred pronouns)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Phone Number (with area code)
*
Your answer
Payment Modality
*
Private Pay
Concierge Services
Aetna
BCBS
Cigna
Oscar
Tricare
United
CompPsych (therapy only)
Humana (therapy only)
ComPsych (therapy only)
Other:
Insurance ID Number (Answer N/A of concierge or private pay)
*
Your answer
Insurance Group Number (Answer N/A of concierge or private pay)
*
Your answer
Is the patient the primary subscriber?
*
Yes
No
N/A (Concierge or Private Pay)
Full name of the primary subscriber. If you are the primary subscriber, enter "self." If self pay or concierge, enter N/A
*
Your answer
Date of birth of primary subscriber.
MM
/
DD
/
YYYY
Legal history. (i.e. custody, divorce, criminal history)
*
Your answer
Detailed reason for your visit. Please include any previous diagnoses, testings, symptoms and referrals, if any (including name/ place of referral)
*
Your answer
Current Medication Regimen
*
Your answer
Past medication trials
*
Your answer
How did you hear about Baobab Psychiatry
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
