Behavioral intake form 2025

1. Click ‘Get Form’ to open the behavioral intake form in the editor.
2. Begin by entering today’s date at the top of the form. Clearly print your last name, first name, and middle name if applicable. Indicate whether this is your legal name.
3. Fill in your marital status by circling one option: Single, Married, or Other. Provide your birth date and address details including street, city, state, and ZIP code.
4. Complete the contact information section by providing your cell phone number (required), work phone number, email address, and alternative email if available.
5. In the insurance section, indicate if you are covered by insurance and provide details about your primary and secondary insurance plans as applicable.
6. List any previous diagnoses you have received and provide an emergency contact's name along with their relationship to you.
7. Review all entered information for accuracy before submitting the form through our platform for processing.

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