HC3: Intake Form

Patient Registration Form & Health Questionnaire

Please complete the Patient Registration Form and Health Questionnaire, then click the "Submit Form" button at the bottom of the form. If you prefer to download hard copies of these forms, click here and you will be able to print out and complete the forms.

Please note: You can use the [Tab] key to navigate from box to box. If you accidentally hit the [Enter] key before the form is completed, it will be submitted as is. Simply use your web-browser's "Back" button to return to the form, complete the forms and resubmit them..

Patient Registration Form

Demographic Information
First Name:
Last Name:
Email Address:
Date of Birth:
Gender:
Marital Status:
SS#:
Referred By:

Contact Information
Street:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:

Insurance Information
Insurance Company:
Policyholder Name:
Policyholder SS#:
Policyholder Date of Birth:
Relationship to Policyholder:
Member ID#:
Group ID#:
Policyholder Employer:


Health Questionnaire

Primary Care Physician
Physician's Name:
Physician's Phone:

Family Members
1 Name / Relationship / Age:
2 Name / Relationship / Age:
3 Name / Relationship / Age:
4 Name / Relationship / Age:
5 Name / Relationship / Age:
6 Name / Relationship / Age:

Emergency Contact
Name:
Relationship:
Phone:

Treatment History
Please complete this section if you have ever received any other therapy or special treatments (including psychological counseling, psychiatric treatment, hospitalization, speech therapy, occupational therapy, medication, special diets, etc).
Type of Treatment / Date(s) / Provider:
Type of Treatment / Date(s) / Provider:
Type of Treatment / Date(s) / Provider:
Type of Treatment / Date(s) / Provider:
Type of Treatment / Date(s) / Provider:

Medical History
Allergies:
Medical Conditions:
Current Medications (and dosage):
Other Health Information:

Comments