Behavioral Health Intake Form - Patient

Patient First Name

Patient Last Name

I have a different preferred name

Preferred Name

Birth Date

Sex Assigned at Birth

Current Gender Identity

Phone Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Referring Provider/Entity (if applicable)

Primary Care Provider Name

Primary Insurance

Insurance ID

Additional Insurance (Secondary)

How did you hear about us?

ID Card (FRONT)

One file only.
4 MB limit.
Allowed types: pdf, png, jpg, gif, tiff, .

ID Card (BACK)

One file only.
4 MB limit.
Allowed types: pdf, png, jpg, gif, tiff.

Questions about how AL!VE can help you reach your goals? Get in touch.