Welcome to the Growth Opportunity Center. Please complete this intake form if you are seeking evalation or therapy services. You will receive a phone call back from us within 12-24 hours to confirm receipt of this intake and to review business procedures. You should not use this form if you have a psychiatric emergency or crisis. In the event of an emergency, you should contact a psychiatric crisis center or go to the nearest emergency room. If you are having difficulty completing or submitting this form, please call our office during normal business hours Monday - Friday 9:00am - 4:30pm at 215-947-8654 dial "0" for office. Thank you and we are looking forward to serving you.
Today's Date is
December 11, 2017
Name of the person filling out this form
Your relationship to the patient
Best phone number to reach you
Your email address
Name of patient if different than the person filling out this form (If you would like to use your health insurance, please write the patient's name exactly as it is listed on the insurance card).
Patient's date of birth
Apt / Suite
Dist of Columbia
Please complete the following information if you would like to use your health insurance. Check the appropiate box from the list of insurance's we accept below.
(Please note that not all clinicians at GOC accept all insurances.)
Keystone Health Plan East
United Behavioral Health
Penn Behavioral Health
Total Care Network
Cardholder's name (exactly as listed on insurance card)
Cardholder's date of birth
Identification number on the front of the insurance card. (Please do not list the group number.)
Please enter the Toll Free number from the back of your insurance card so we can verify your Behavioral Health Benefit.
If you are seeking services for a child, please complete the following:
If parents are separated, divorced or never married, please complete the following:
Do parents have joint legal custody?
Mother's Full Name
Mother's complete Home Address
Phone: Mother's Home
Father's Full Name
Father's complete Home Address
Phone: Father's Home
Reason for seeking services?
Please tell us in a few sentences what type of service you are interested in and why you are seeking services at this time:
Has the patient ever been hospitalized for anything related to mental health in the past?
If yes, how long ago and in which in-patient treatment facility?
Is the patient currently taking medication for a psychiatric related issue?
Is the patient seeing another therapist or psychiatrist at another location?
If yes, where and with whom?
Was the patient ever treated at Growth Opportunity Center in the past?
If yes, with whom and how long ago?
Would you like to request a specific clinician? If so visit our website
and view our clinicians' profiles. Please note that not all clinicians are able to take new patients and not all clinicians accept all insurances. If your requested clinician is not available, we will make every attempt to match you with someone with similar training and approach to treatment.
What time of day would you be available to be seen?
Please list days of the week and times (mornings, daytime, after school, evenings, or weekends).
Do you have any other preferences of which we should be aware?
Other important information:
Please click the Submit button below and we will be in touch shortly.