Middletown Counseling Intake Form
Inquiry Date ____________ Previous Client? Y N
Caller Name _____________________________________________
Caller’s Phone Numbers
Client’s Name ________________________________ DOB _____________
SOCIAL SECURITY # (FOR ELECTRONIC BILLING PURPOSES)_______________
Subscriber’s Name ___________________________ DOB _____________
Employee Assistance Program? ____________ Company__________________
Auth Number _________________________________ Number of Visits ___________
Please remind client to call for authorization number & amount of visits authorized if unknown.
OR
Type of Insurance______________________________
ID #_______________________________ Group #________________________
Phone # on the back of the card for mental health/substance abuse preauthorization:
Requesting Therapist _____________________
Service Location _____________________
Problem: ________________________________________________________________________________________________________________________________________________________________________________________________________________________