Mental Health Provider Intake Form [PDF]

mental health intake form templateWe wanted to share our “vanilla” mental health intake form PDF template with our community.

If you find this page useful, consider sharing it as a resource with a colleague needing help starting their own private practice.

If you are sick of dealing with insurance billing or have never considered a life without insurance billing, consider reaching out about our billing service exclusively for licensed mental health providers.

Below in PDF and Doc file formats is our intake form.  We have our slightly modified for the providers we work with in our billing service, but this is a great one to utilize in your private practice, especially if you take insurance.

Our document helps you collect demographic information like:

  • Full Name
  • Gender
  • Date of Birth
  • Address

And essential insurance information such as:

  • Insurance company name
  • Client’s subscriber ID (with all letters / prefixes / postfixes)
  • The provider customer service phone number on the back of the card, or the mental health customer service number, if indicated on the card

Download the PDF copy of our intake form for mental health providers:

Download your Word doc / docx copy of our mental health intake form here:

Quick Intake Tip!

If you have a new patient, take out your smart phone or digital camera and snap the front and back of their card.  You don’t need to do anything with it unless you need it, but if you do need it, you’ll have that information.  Often times folks can give you slightly incorrect or hard to read information.  A copy of their insurance card is very helpful to have on file.

We save all of this information on a unique client profile for you with our billing service at TheraThink, so you always have access to every insurance card we have on file for that client.   HIPAA compliant of course!

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Need billing help?  Considering reaching out to us @ TheraThink