New Patient Intake Form

Today's Date is January 14, 2025

Patient information

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 *

Street Address *

Apt / Suite

City *

State *

ZIP

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: Married Single Divorced Widowed

If parents are separated, divorced or never married, please complete the following:

Do parents have joint legal custody? Yes No

Mother's Full Name

Mother's complete Home Address

Phone: Mother's Home

Mother's Work

Mother's Cell

Father's Full Name

Father's complete Home Address

Phone: Father's Home

Father's Work

Father's Cell

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? Yes No

If yes, how long ago and in which in-patient treatment facility?

Is the patient currently taking medication for a psychiatric related issue? Yes No

Is the patient seeing another therapist or psychiatrist at another location? Yes No

If yes, where and with whom?

Was the patient ever treated at Growth Opportunity Center in the past? Yes No

If yes, with whom and how long ago?

Would you like to request a specific clinician? If so visit our website gocenter.net 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.