Adult Intake/Screen  
Sign in to Google to save your progress. Learn more
Client Name *
Does the client have a different legal name? If so, please put it below
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Gender Identity
Pronouns
Street Address Line 1 *
Street Address Line 2
City *
State *
Zip Code *
Phone Number *
Email Address *
Is it okay to leave a message? *
Are you a previous client? *
Who were you referred by? *
Were you referred to a specific clinician? PLEASE NOTE: Requesting a specific therapist at the clinic can prolong the wait time *
What is your availability for an appointment? *
Is the above availability flexible? *
Our clinic will sometimes get cancellations and appointments open up at the last minute. Would you like to be added to our cancellation list to be contacted when a last minute appointment comes up? Please note, these slots only come up occasionally, and if they are rejected, you will still be on our waitlist for the usual amount of time
 *
I do not have insurance with BCN or BCBS. I would like information regarding sliding scale payment options. In order to qualify for these options, I will need to submit tax returns, pay stubs or other approved proof of income *
Primary Insurance Information
Insurance Company *
Subscriber ID/Contract Number *
Group Number *
Employer *
Policy Holder *
Policy Holder DOB *
MM
/
DD
/
YYYY
Policy Holder Relationship to Client *
Secondary Insurance Information
If no secondary insurance information, you may skip this section
Secondary Insurance Company
Secondary Subscriber ID/Contract Number
Secondary Group Number
Secondary Insurance Employer
Secondary Insurance Policy Holder
Secondary Insurance Policy Holder DOB
MM
/
DD
/
YYYY
Secondary Insurance Policy Holder Relationship to Client
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Anxiety and OCD Treatment Center of Ann Arbor. Report Abuse
Google Forms