ICGH Mental Health Intake Forms
PLEASE READ FULLY:
Please take the time to complete these forms completely.  It should take about 30 minutes read and answer everything. Please answer all questions honestly, including all screening tools and health history questions, as this helps us to match your assessment with the correct clinician to help you make the most of your treatment.  Please do not click back on your browser while working on this packet, as this will cause all information you have put in to be lost.  Only use the BACK and NEXT buttons at the bottom of each page, as this will save information between pages.
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First name: *
Middle Name: *
Last Name: *
Is this your legal name?: *
Legal Name (If different):
Maiden Name:
Date of Birth: *
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DD
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YYYY
Social Security Number: *
Gender: *
Sexual Orientation: *
Race: *
Required
Ethnicity: *
Required
Primary Language: *
Required
Veteran: *
Required
Street Address: *
City: *
State: *
Zip Code: *
County: *
How long have you lived at this address?: *
Is this residence owned by your or by family?: *
Primary Phone Number: *
Secondary Phone Number:
Email: *
May we leave voicemail messages at the above numbers?(Messages may relate to appointment information, scheduling, requests for medication counts, or notifications of appointment cancellation due to unforeseen circumstances): *
May we send text messages to the above numbers? (Messages may relate to appointment information, scheduling, requests for medication counts, or notifications of appointment cancellation due to unforeseen circumstances): *
How did you hear about us?: *
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