Patient Intake Form - Wellspring Family & Community Institute

Welcome to Wellspring Family & Community Institute. As a new patient, please fill out our intake form to submitted to our staff.

PATIENT INFORMATION

Full Legal Name

Date of Birth

Social Security Number (SSN)

Home Phone Number

Work Phone Number

Cell Phone Number

E-mail

Contact Method Preference

Street Address

City

State

Postal Code

Legal Gender

Sexual Orientation

Gender Identity

Martial Status

Religion

Preferred Language

Emergency Contact Name

Relationship

Phone Number

Who Referred You?

Current Employment

Employer

Primary Doctor

Medical Provider

Communications between health care providers can be beneficial to your receiving services and establishing continuity of care. Your permission is required for this communication. Please check one of the following:

Select an Option

I DO NOT have a primary health care provider.

NO, I do not want communication with my primary health provider.

YES, I want communication with my health care provider.

If YES, we will require a letter or phone call to indicate that you have been seen at this location.

If Other, Please Specify

Primary Insurance Company

Policy Holder (Name)

Policy Number

Employer/Group #

Social Security Number (SSN)

Secondary Insurance Company

Policy Holder (Name)

Policy Number (Second)

Employer/Group #

Social Security Number (SSN)

Have you ever been hospitalized for psychiatric reasons?

Yes

If yes, what were the circumstances? Please include dates:

When was your last full physical exam?

Any physical issues?

Reasons for seeking counseling at this time?

Please check any of the following conditions that currently apply to you

Check everything that has happened to you in the past two years:

If other, pleas specify:

Consent for Evaluation and Treatment

I hereby give consent for evaluation and treatment. It is agreed that either of us may discontinue the evaluation and treatment at any time and that I am free to accept or reject the treatment provided.

In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardian of the child and that I authorize services
for the child under the terms of this agreement.

Full Name

Today's Date

In the case of a minor child, please specify the following:

Full Name of Minor

Date of Birth

Relationship

How would you like to be contacted for reminder calls for follow up appointments and reminder calls. Please check and provide
the appropriate information.

Via Text Message

Via Phone Call

Via Email

Failure to provide timely information about your Health Insurance can result in you being totally responsible for the cost of services provided. Many insurance(s) require billing to be done in a “timely manner” and will not pay claim submitted after the allotted time.