CLIENT INTAKE FORM:


Date:______________


PARTICIPANT/PATIENT INFORMATION:

Name of Client:

DOB:___________Age_____

Phone #:

Address_____________________________________.

City _______________State______Zip________

Emergency Contact Number ( ______________)

Name/Relationship ________________


FACILITY INFORMATION:

Hospital/Medical Center:____________________________

Date hospitalized____________________

Dx______________________

Surgery?_______________

Contact/Case Manager:_______________________

Phone #:__________________________

Fax #:_____________________________________



PHYSICIAN INFORMATION:

 Physician/Provider Name:______________________________

Specialty________________________

Phone #:___________________________________

Contact:___________________________________

Fax #:_____________________________________

Last visit____________________

 
Physician/Provider Name:______________________________

Specialty_________________________

Phone #:___________________________________

Contact:___________________________________

Fax #:_____________________________________

Last visit________________________

 
Other provider Name______________________________

Specialty___________________________________

Phone #__________________________________

Contact______________________________

Fax___________________________

Last visit_________________________

 

REQUESTED SERVICES:

Type of Service received/ needed: 􀀀 In-Patient 􀀀 Out-Patient 􀀀Home Health 􀀀 DME 􀀀 Infusion 􀀀 PT 􀀀 OT 􀀀 SP      Pain Management     Long Term Care

DX:_________________________________________________________________

ICD 9 Codes: _________________

Procedure/CPT Codes:_______________


Did this injury or illness occur during the course of employment? Yes No

Records Requested from _________________________ Records Received ______________

Records Requested from _________________________ Records Received ______________

Records Requested from _________________________ Records Received ______________

 

PRESENTING PROBLEM/CASE MANAGEMENT NEED:                                                                                               (type of illness, injury, disability and complaint with whom…physician, hospital, etc?)

 

 MENTAL HEALTH:

Receiving mental health counseling?   Yes No

Clinician:__________________________________________                   Phone:____________________

Dx_____________________________________

Has client ever received mental health counseling?  Yes No 

When______________________ For how long? _________________

Ever hospitalized for a psychiatric condition?Yes No

Most recent date:______________________  Where?________________________

____________________________________________________________


PRIMARY INSURANCE:


Indicate all that apply:

Medicare #__________________________

Medicaid: Number with Sequence # ___________________________

Private Insurance:__________________________ID__________________

Phone:_______________________

Effective date:_____________________

 
SECONDARY INSURANCE:

Name_____________________________

ID #_____________________________

Phone________________________

Effective Date of Secondary Insurance: ___________________
 

MEDICATIONS: (Name, dosage, etc.)


OTHER NEEDS:

 
SUMMARY NOTES:

 

​       "Caring Is Our Business"