General Intake Form: Santa Fe & Rio Arriba FOR SANTA FE AND RIO ARRIBA COUNTIES ONLY. Intake forms are securely encrypted and HIPAA compliant. General Intake Form: Santa Fe & Rio Arriba 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 Specify RACE/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) CITY STATE ZIP PHONE 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*PSYCHIATRIST PSYCHIATRIST PHONEPRIMARY CARE PHYSICIAN PRIMARY CARE PHYSICIAN PHONEPAYMENT TYPE* PRIVATE INSURANCE MEDICAID PRIVATE PAY INSURANCE NAME* POLICY NUMBER* CO-PAY AMOUNT* PRIMARY INSURED’S NAME (IF DIFFERENT THAN ABOVE) PRIMARY INSURED’S SSN PRIMARY INSURED’S DOB PRIMARY INSURED’S SEX Female Male Or: Please Specify PRIMARY INSURED'S EMPLOYER OR SCHOOL PRIMARY 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 NUMBER CASH, 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 LIST INSURANCE INFORMATION FOR ADDITIONAL FAMILY MEMBERS REQUIRING SERVICES