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Psychiatric Child and Adolescent Intake/Screen
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* Indicates required question
Client Name
*
Your answer
Does the client have a different legal name? If so, please put it below
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Sex
*
Male
Female
Other:
Gender Identity
Your answer
Pronouns
Your answer
Street Address Line 1
*
Your answer
Street Address Line 2
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Parent/Guardian
*
Your answer
Does your child live with both of his/her legal parents? If not, the name, address or email address and phone number for the joint legal parent is required.
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Is it okay to leave a message?
*
Yes
No
Are you a previous client?
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Yes
No
Who were you referred by?
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Your answer
What is your availability for an appointment?
*
Your answer
Is the above availability flexible?
*
Yes
No
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
*
Yes
No
I have BCN or BCBS
Primary Insurance Information
Insurance Company
*
Your answer
Subscriber ID/Contract Number
*
Your answer
Group Number
*
Your answer
Employer
*
Your answer
Policy Holder
*
Your answer
Policy Holder DOB
*
MM
/
DD
/
YYYY
Policy Holder Relationship to Client
*
Your answer
Secondary Insurance Information
If no secondary insurance information, you may skip this section
Secondary Insurance Company
Your answer
Secondary Subscriber ID/Contract Number
Your answer
Secondary Group Number
Your answer
Secondary Insurance Employer
Your answer
Secondary Insurance Policy Holder
Your answer
Secondary Insurance Policy Holder DOB
MM
/
DD
/
YYYY
Secondary Insurance Policy Holder Relationship to Client
Your answer
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