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 DOB ON ADDITIONAL INSURANCE POLICYPRIMARY INSURED’S SEX ON ADDITIONAL INSURANCE POLICY Female Male Or: PRIMARY 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 HAVE THE SAME INSURANCE INFORMATION AS LISTED ABOVE?* YES NO Please SpecifyLIST INSURANCE INFORMATION FOR ADDITIONAL FAMILY MEMBERS REQUIRING SERVICES
