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Healing Hearts Intake Form
Thank you for expressing interest. If you are considering taking that next step on your recovery journey, please fill out the below new patient intake form and someone will reach out to you to schedule your admission appointment. This form is HIPAA compliant.
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Intake Questions (part 1)
The below questions will help us to get you set up with an initial appointment. Someone will contact you within the next 24 business hours to schedule your appointment. You may also contact us via phone call or text at (419) 528-5993 ext. 101.
Name
*
Your answer
Are you a new or returning client?
*
New Client
Returning Client
Address (include city, state, and zip code)
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Non-binary
Transgender
I prefer not to say
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Race / Ethnicity
*
Your answer
Social Security Number
*
Your answer
What's bringing you into treatment? Please include substances you are currently struggling with.
*
Your answer
Are you currently suicidal? If you are in immediate crisis or a danger to yourself please call 911 or go to your nearest emergency room.
Yes
No
Clear selection
Are you being court ordered for treatment? If so, are you currently on probation or awaiting sentencing?
*
Yes
No
Emergency Contact
Please complete the questions below with someone who can be reached in a emergency. This will only be used in emergency circumstances.
Name of Emergency Contact
*
Your answer
Relation of emergency contact (parent, friend, spouse, etc.)
*
Your answer
Contact Number for Emergency Contact
*
Your answer
Insurance Information
Please provide your insurance information below
Insurance type
*
Medicaid
Medicare
Private / Commercial Insurance
No insurance / Self-pay
Insurance Provider
*
Your answer
Intake Questions (part 2)
The rest of the form is not required for us to contact you - however, the following questions below we will need to ask you when we speak on the phone. You can either opt out now or continue filling out the questions.
The address you provided us with, is that
Your home
Others home
Temporary housing
Homeless
Clear selection
Is there anyone under the age of 18 in your home? If so, how many individuals are there?
Your answer
What is your primary source of income at this time?
Disability (SSI/SSD/WD)
Family/Relative
Wages/Salary
None
Public Assistance
Other
Retirement/Pension
Unknown
Clear selection
Are you a current nicotine user?
Yes
No
Clear selection
What is your Military status?
Active
Discharged
Disabled Veteran
None
Clear selection
Are you currently enrolled in any schooling?
Yes
No
Clear selection
What is your highest level of education?
Your answer
Please list any known allergies
Your answer
Are you currently taking any prescribed medications?
Yes
No
Clear selection
Do you have a medical condition or infectious disease that we should be aware of so we can better assist you?
Your answer
How did you hear about us?
Your answer
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