Online Intake Form | Omaha NE | Envision Counseling Center LLC

Name*

First Last

Date of Birth*

Gender*

Male
Female
Other

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone*

Is it OK to call and leave a message*

Yes
No

Social Security Number

Who is your current employer?

Relationship Status*

If partnered or married, what is your partner/spouse's name?

Emergency Contact | Name*

First Last

Relationship*

Phone*

If the client is younger than 19 years old: Parent/Guardian Name

First Last

If the parents are divorced: Custodial Parent Name

First Last

Phone

Is there joint custody?

Yes
No

Primary Care Physician's Name

Phone

Psychiatrist's Name (if applicable)

Phone

Do you have any allergies?*

Yes
No

If yes, please list (click (+) to add more than one).

Are you currently taking any medications?*

Yes
No

If yes, please list (click (+) to add more than one).

Insured/Responsible Party Name

Insured/Responsible Party Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured/Responsible Party Phone

Insurance Company

Policy Number

How did you hear about us?

Website

Briefly describe what you would like accomplish in counseling

Acknowledgement*

I acknowledge entering my name below is equivalent to a handwritten signature.

Client Signature*

Date*

MM

DD

YYYY

Privacy*

By using this form you agree with the storage and handling of your data by this website. *

Envision Counseling Center, LLC

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