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Intake Form
Please note that this is a request to start services. Someone from our office will contact you within 24 - 48 business hours to schedule.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
What state does the client reside in? (Currently Changing Tides Counseling & Behavioral Health, LLC provides services to residents of Maryland, District of Columbia, & Virginia).
*
Maryland
District of Columbia
Virginia
Other:
Client First Name
*
Your answer
Client Last Name
*
Your answer
Custodian/Guardian Name (if applicable)
Your answer
Primary Language
*
Your answer
Client Date of Birth
*
MM
/
DD
/
YYYY
Client Gender
*
Female
Male
Prefer not to say
Other:
Client Race
*
White
African American/Black
Hispanic
Native American
Asian
Other
Physical Address
*
Your answer
Zip Code
*
Your answer
Home Number
*
Your answer
Cell Number
*
Your answer
Is it okay to leave a voicemail on this number?
*
Yes
No
Is it okay to send a text message to this number?
*
Yes
No
Primary Care Provider
Your answer
Primary Care Provider Telephone #
Your answer
Services Paid By
*
Insurance
Private Pay
Required
Who is your insurance provider
Blue Cross Blue Shield
Aetna
Cigna
United Health Care
Florida Blue
Magellan
Medicare
Medicaid
Other:
Clear selection
Do you have Medi- CAL coverage?
*
Yes
No
Do you have Medicaid coverage?
*
Yes
No
Insurance Provider
Your answer
Insurance ID#
*
Your answer
Availability
*
Morning
Afternoon
Evening
Anytime
Reason For Referral
*
Your answer
How did you hear about us?
*
Facebook
Instagram
Psychology Today
Black Girl Therapy
Our Changing Tides Website
A friend/current client
Other:
Therapist Preference ( You can find our therapist on our website)
*
Your answer
Comments
Your answer
Send me a copy of my responses.
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