Intake Forms

Intake Referral Form

Complete the form below and click Submit. Your responses go directly to our office.

1. Who Is Completing This Form

Name of person completing form *How are you related to the client?

2. Identifying Information (for individual receiving services)

Name *Date of birth *AddressSexMarital statusHome phoneWork phoneSocial Security numberOptional — leave blank if you prefer.Household income ($)Who referred you to Loving Helping Hands?RaceLanguage of choiceReligious affiliation

Do you have a disability?

YesNo

Does the office accommodate your needs?

YesNo

If the therapist should be aware of any special treatment considerations due to gender, age, sexual orientation or cultural, religious, national, racial, or ethnic identity, please explain:

4. Family History

1. Were drugs or alcohol a problem in your family when you were growing up?

YesNo

2. Do you or another family member have a history of alcohol or drug problems?

YesNo

3. Please describe your current alcohol consumption

4. Was there any type of abuse (physical, sexual, domestic or emotional) in your family or home?

YesNo

5. Have you or any other family member experienced any type of abuse?

YesNo

5. Legal History

Please describe any involvement you have had with the legal system (arrests, convictions, probation, parole)

6. Current Family Information

Spouse/significant other — name (first and last)Spouse/significant other — date of birth

Spouse/significant other lives with you?

YesNo

Children live with you?

YesNo

Others living in the household

Military service

YesNo

OccupationCurrent employer

8. Goals

1. What are your strengths?2. What are your weaknesses?3. What goals would you like to see reached?

9. Insurance Information

Primary insurance — group numberPrimary insurance — policy numberSecondary insurance — group numberSecondary insurance — policy number

10. Signature & Consent

Signature — type your full legal name *Typing your full legal name acts as your electronic signature.Client name (print) *Date *I have read the Notice of Privacy Practices included in this Intake Referral Form and consent to Loving Helping Hands, Inc. using my protected health information for treatment, payment, and healthcare operations as described. *

Please do not email sensitive personal health information outside this form. Completed forms may also be brought to your first appointment or submitted in person at our office.

Intake Referral Form

1. Who Is Completing This Form

2. Identifying Information (for individual receiving services)

3. Presenting Problem (current situation and history)

4. Family History

5. Legal History

6. Current Family Information

7. Medical History

8. Goals

9. Insurance Information

10. Signature & Consent

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