COUPLE/FAMILY Intake Form

Download Couple/Family Information Form

Or Complete Form and Sign Below

    Current Date:

    Referred By:

    Primary Client Name:

    Preferred Name:

    Date of Birth:

    Age:

    SSN:

    Mental Health MEDICATION:

    Parent or Partner Name:

    Preferred Name:

    Date of Birth:

    Age:

    SSN:

    Mental Health MEDICATION:
    Children's Name/Ages:

    IF UTILIZING INSURANCE BENEFITS, PLEASE FILL IN THE FOLLOWING FIELDS

    If covered under spouse/parent's insurance:
    PRIMARY COVERAGE's



    I authorize the release of any medical information necessary to process this claim. I request the payment from my insurance company be made directly to Angie L. Heath, LCSW with Clinical Conversations, Inc or (if utilizing out of network benefits, request payment of benefits either to myself or to the party who accepts assignment below).
    I permit a copy of this authorization to be used in place of the original.

    Signature: (Patient, Parent, or Legal Guardian)

    Date:

    APPOINTMENT REMINDERS

    You can receive an appointment reminder via text. This service is from Jituzu.com which is HIPAA compliant and is no charge to you. We input the minimal information (your name) into their system along with your phone number.
    Would you like to receive appointment reminders?YesNo