Clinical Psychology Intake Form

Patient’s Legal Name *

First

Last

Patient’s Preferred Name *

Patient’s Date of Birth *

Patient’s Birth Sex *

Phone Number *

Patient’s Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you currently have Independent Health insurance? *

Are you currently enrolled in Medicaid? *

***This section is for patients under 18-years-old or for any patient that has a legal guardian***

Name of Parent/Legal Guardian

First

Last

Relationship to the Patient *

you Patient’s

Phone

Are you involved in any litigation (suing someone and/or being sued)?

If YES, please elaborate

*** Please note a provider referral is not required***

Is someone referring you? If so, whom?

***Please select the Testing Service that you are interested in pursuing***

What services are you looking for? *

Check the following to continue. *

 I understand that this is a private pay service and that the total cost of services will be discussed with the provider following the initial consultation(s). I understand that the cost of the initial consultation is $250 per appointment. For pediatric patients, two initial consultations are required, for a total cost of $500. I understand that payment for the initial consultation(s) is due prior to attending the appointment. I further understand that the cost of the initial consultation(s) will be applied toward the total cost of the evaluation and appropriate testing.

Patient Signature *

Clear Signature

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