Form_Client Intake Form – Building Bridges Through Communication (BBTC)

Client Intake Form – Insurance/Self-Pay

Client Information

Client's Name

First

Last

Client's Date of Birth

Client's Email

Client's Phone#

Client's Address

Address Line 1

City

State

Zip Code

Client's Diagnosis

Physician's Information

Physician's Name

First

Last

Physician's Address

Address Line 1

City

State

Zip Code

Physician's Phone#

Physician's Fax#

Insurance Information

Insurance Carrier

Name of Insured

First

Last

Insured's Date of Birth

Employer's Name

Employer's Address

Address Line 1

City

State

Zip Code

Group Number

Policy Number

Member ID Number

Social Security Number

Guardian Information

Emergency Contact Information

Guardian's Name

First

Last

Emergency Contact's Name

First

Last

Guardian's Phone#

Emergency Contact's Phone#

Guardian's Email

Emergency Contact's Email

Case Manager Information

Case Manager's Name

First

Last

Case Manager's Phone#

Case Manager's Email

Case Manager's Fax#

Are You Interested in Telehealth?

How did you hear about BBTC?

Client's Name Insurance

Additional Comments

Please upload a copy of your insurance card (front and back) before selecting Submit.

Click or drag a file to this area to upload.