Intake – Step 3 – Other – Home

Once you complete the questions on this page, your message will be sent to the intake coordinator as SD Associates.

Page 3 of 3

    Person Submitting This Form

    Your First & Last Name (required)

    Your Agency/Business (required)

    Your Email (required)

    Your Phone Number (required)

    Your Relationship to Parent/Guardian/Client (required)

    Parent / Guardian Information

    First & Last Name (required)

    Date of Birth

    Address

    Email (required)

    Phone Number (required)

    Client / Dependent Information

    Client's First & Last Name (required)

    Client's Date of Birth (required)

    Client's Address (if different)

    Client's Primary Diagnosis (required)

    Date of Diagnosis

    Secondary Diagnosis

    Client's Primary Care Physician (required)

    Address of Primary Care Physician

    Phone Number of Primary Care Physician

    Referring Provider

    Address of Referring Provider

    Phone Number of Referring Provider

    Insurance Information

    Insurance Company (required)

    Member's Name (required)

    Member's Place of Employment

    Address of Member's Employer

    Member's Address (if different from above)

    Member's Phone (if different from above)

    Member's Date of Birth (required)

    Note: If you will be receiving insurance information that you have not yet obtained, please input "none" into the following 4 insurance questions.

    Insurance ID # (required)

    Insurance Group Number

    Insurance Phone Number (on back of card)

    Insurance Address (on back of card)

    Secondary Insurance Information (if applicable)

    Insurance Company

    Member's Name

    Member's Date of Birth

    Insurance ID #

    Insurance Group Number

    Insurance Phone Number (on back of card)

    Insurance Address

    Current Concerns

    Diagnosis

    Does the client use aggression towards self or others to communicate?

    YesNo

    Please explain how client manages social structures

    Do you have any final questions for me?

    What is the best way to contact you?

    PhoneEmail

    Final Step

    By checking this box, you are digitally signing this form and agreeing to our privacy policy. You confirm that you are voluntarily submitting accurate information so that SD Associates may research options for you and the client based on the data you've provided. You also give SD Associates permission to share this information internally with other staff if deemed necessary.

    I Agree

     

     

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