Behavioral Health Intake Form - Not the Patient

Your First Name

Your Last Name

Your Phone Number

Relationship to patient

Best person to contact for scheduling

Best contact method

Patient First Name

Patient Last Name

Patient Birth Date

Patient has a different preferred name

Patient's Preferred Name

Patient's Sex Assigned at Birth

Patient's 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.