General Intake Form FOR BERNALILLO, SANDOVAL & VALENCIA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant. General Intake Form ID # WERE YOU REFERRED BY A REPRESENTATIVE AT SOUTHWEST FAMILY GUIDANCE CENTER TO COMPLETE THESE FORMS?* YES NO WHO REFERRED YOU TO FILL OUT THESE FORMS?PLEASE CALL (505) 830-1871 FOR ASSISTANCE BEFORE PROCEEDING WITH INTAKE FORMS. THANK YOU!CLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB MM slash DD slash YYYY EMAIL* DATE* MM slash DD slash YYYY SEX* FEMALE MALE OR: Please SpecifyRACE/ETHNICITY*SS NUMBER*PRIMARY LANGUAGE*CHECK ALL THAT APPLY* CHILD NEVER MARRIED MARRIED DIVORCED STUDENT EMPLOYED EMPLOYER/SCHOOL*RESIDENTIAL ADDRESS*CITY*STATE*ZIP*MAILING ADDRESS (If Different)CITYSTATEZIPPHONE 1*PHONE 2IS THE CLIENT UNDER 18 YEARS OF AGE?* YES NO IF UNDER 18: GUARDIAN NAME + RELATION*DO ANY ADDITIONAL FAMILY MEMBERS REQUIRE SERVICES?* YES NO ADDITIONAL FAMILY MEMBERS TO INCLUDE*NAMEDOBSSN EMERGENCY CONTACT NAME/RELATION*EMERGENCY CONTACT PHONE*PSYCHIATRISTPSYCHIATRIST PHONEPRIMARY CARE PHYSICIANPRIMARY CARE PHYSICIAN PHONEPRIMARY PAYMENT TYPE* PRIVATE INSURANCE MEDICAID PRIVATE PAY PRIMARY INSURANCE NAME*PRIMARY POLICY NUMBER*CO-PAY AMOUNT (PRIMARY INSURANCE)*PRIMARY INSURED’S NAME (IF DIFFERENT THAN ABOVE)PRIMARY INSURED’S SSNPRIMARY INSURED’S DOBPRIMARY INSURED’S SEX Female Male Or: Please SpecifyPRIMARY INSURED'S EMPLOYER OR SCHOOLPRIMARY INSURED'S RELATION TO CLIENT Spouse Child MEDICAID TYPE* Blue Centennial Magellan Conduit Western Sky I Don't Know MEDICAID ID # (Blue Card)*CENTENNIAL HEALTHCARE ID NUMBERCASH, CHECK AND CREDIT CARDS (VISA, MASTERCARD & DISCOVER), ALBUQUERQUE OFFICE ONLY RATES: $65 INITIAL VISIT (INTAKE) / $55 REGULAR VISIT / PRICES FOR SPECIAL SERVICE VARYSECONDARY PAYMENT TYPE* NONE PRIVATE INSURANCE MEDICAID PRIVATE PAY ADDITIONAL INSURANCE NAME*ADDITIONAL POLICY NUMBER*CO-PAY AMOUNT ON ADDITIONAL INSURANCE POLICY*PRIMARY INSURED’S NAME ON ADDITIONAL INSURANCE POLICY (IF DIFFERENT THAN CLIENT NAME ABOVE)PRIMARY INSURED’S SSN ON ADDITIONAL INSURANCE POLICYPRIMARY INSURED’S DOB ON ADDITIONAL INSURANCE POLICYPRIMARY INSURED’S SEX ON ADDITIONAL INSURANCE POLICY Female Male Or: Please SpecifyPRIMARY INSURED'S EMPLOYER OR SCHOOL (FOR ADDITIONAL INSURANCE POLICY)PRIMARY INSURED'S RELATION TO CLIENT (FOR ADDITIONAL INSURANCE POLICY) Spouse Child MEDICAID TYPE* Blue Centennial Magellan Conduit Western Sky I Don't Know MEDICAID ID # (Blue Card)*CENTENNIAL HEALTHCARE ID NUMBERCASH, CHECK AND CREDIT CARDS (VISA, MASTERCARD & DISCOVER), ALBUQUERQUE OFFICE ONLY RATES: $65 INITIAL VISIT (INTAKE) / $55 REGULAR VISIT / PRICES FOR SPECIAL SERVICE VARYDO ALL ADDITIONAL FAMILY MEMBERS THAT REQUIRE SERVICES HAVE THE SAME PAYMENT INFORMATION AS LISTED ABOVE?* YES NO NOT APPLICABLE LIST INSURANCE INFORMATION FOR ADDITIONAL FAMILY MEMBERS REQUIRING SERVICES
