New Client Intake – Heredia Therapy Group

I am completing this form…*

Parent(s) Names*

You will fill out the child’s information below under “Demographic information”

Which Language*

How did you hear about Heredia Therapy Group?*

If other, please indicate how:*

Which office are you referring from*

If other, please indicate how:*

Child's Date of Birth*

Client's Date of Birth*

You selected an "other" field on services that you are interested in. Please expand on the services you are interested in, so our team can determine if it is within the scope of practice of what we are able to offer.*

Demographic Information

Client's First Name*

Client's Last Name*

Phone Number:*

Secondary Phone Number

Client's Email*

Parent's Email*

How would you like to cover your services?*

What is your budget for services?*

Please expand*

i.e. Victims of Crime (V.O.C), HSA Card, Etc.

Do you know your CIN number? Please enter it below*

If not, please indicate by stating “I don’t know”

Health Insurance Name*

Frequently, mental health benefits are processed through different insurance panels than the ones listed on your insurance card. If your insurance is not included in this list, please don’t hesitate to seek mental health assistance. Simply choose the “Other” option, and our team will review your benefits to inform you about the available options.

Name of "other" Insurance*

Please note that if Heredia Therapy Group is not in network with your insurance provider, we will exhaust all resources to verify if we can or cannot see you through your insurance carrier.

Insurance Member ID*

Upload a copy of your insurance card*

Max. file size: 256 MB.

Partner's information

Please fill out this section if your partner also has health insurance. If you are both on the same health plan, it is not necessary to fill in this information, and you can leave it blank

Select which option more closely aligns with your situation*

Please note, that if you are in a domestic partnership, marriage, civil union or other legal relationship, and the insurance provided is not the primary coverage, you may be subject to financial responsibility.

Partner's Date of Birth*

Partner's Health Insurance

Name of "other" Insurance*

Please note that if Heredia Therapy Group is not in network with your insurance provider, we will exhaust all resources to verify if we can or cannot see you through your insurance carrier.

Partner's Insurance Member ID

Upload a copy of your partner's insurance card

Max. file size: 256 MB.

Clinical Demographics

Name(s)*

Name(s) of family members*

We ask for this information to protect your confidentiality, and prevent the same family member from receiving services with the same therapist.

Do you have a history of Mental Health Services? If so, what were the outcomes?*

Reason for seeking services (i.e. depression, anxiety, ASD, medication management) Please be as detailed as possible.*

Availability for ongoing services*

Once verified, When would you like your weekly sessions to occur. Please note, that the maximum amount of flexibility you provide, the faster we are able to match you with a therapist!

If yes, please explain.*

When did you last have thoughts. What are the frequency of the thoughts, etc.

If yes, please explain.*

be sure to include the date of the last hospitalization, duration of the hospitalization, discharge recommendations.

Please include the discharge documentation

Max. file size: 256 MB.

You can upload it here, or you will be asked to upload at a latter time.

If yes, please explain.*

i.e. drinking alcohol, marijuana, vaping, etc

If yes, please explain.*

i.e. drinking alcohol, marijuana, vaping, etc

Adolescent Particulars

Point of Contact/ Pertinent Information*

You will be asked to provide the office with a current copy of your custody documentation. You can upload the documentation here to help expedite the process, or you can provide it to the office at a latter time.

Max. file size: 256 MB.

Do you have a history of ABA Services? If so, what were the outcomes?*

You can upload a copy of that report now

Max. file size: 256 MB.

If you do not have it on hand. No worries, please feel free to submit the form anyways, but please note, that the office will be asking for a copy before proceeding with services.

Additional Questions

Please note, that Heredia Therapy Group does not get involved in any legal cases. You will be asked to sign the disclosure upon completion of intake.

Are you seeking online or in-person services?*

Which Location?*

If yes, please explain.*

Please indicate below the best time(s) to reach you by phone.*

Please note, that our administrative office is only open M – F until 5:00 pm

Preferred method of communication*

Please note, that although your preferred method of communication is not phone call. Heredia Therapy Group may contact you via phone to confirm the information provided is accurate. As such, please indicate some time below the best time(s) to reach you by phone.*

Communication and scheduling through text message is not an approved form of communication, and as a result, will only be used for appointment reminders.

Comments

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