Intake Form | NextGen Behavioral Wellness Center LLC

1

Client Information

Client First Name *

Client Last Name *

Date of Birth *

Diagnosis (if any)

School / Program

Primary Language

Insurance Provider (if applicable)

Member ID / Policy ID

Group Number

Policy Holder Name

Primary Care Physician

2

Full Name *

Relationship to Client *

Phone Number *

Email Address *

Mailing Address

City

State

Zip Code

3

How Did You Hear About Us?

Primary Concerns

Goals for Services

Previous Therapy or Services

4

Please list any other concerns

5