Client Intake Form Please enable JavaScript in your browser to complete this form.12345Name *FirstLastToday's Date *Parent or Guardian FirstLastIf client is a minorNextAge *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number *Can we Leave a Voice Mail? *YesNoAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmailConfirm EmailAre you willing to be seen via Telehealth (video session)? *YesNo Maybe PreviousNextInsuranceNoYesTypePlanMember ID *Policy Holder Name *FirstLastPolicy Holder Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Group NumberPhone Number of ProviderLocated on back of policy cardPreviousNextHow did you hear about Avenue's Counseling, LLC?Tell us a little about why you are looking to be seen.How long have these challenges been in your life?Have you had any thoughts of suicide, or suicide attemptsNoYesPlease explainDo you currently, or do you have a history of self harm?NoYesPlease explainPreviousNextHave you ever been hospitalized for your mental health?NoYesPlease describeDo you have any past therapy experiences?NoYesPlease describeAny current or past psychiatric care?NoYesPlease describeDo you have a history of drug or alcohol use?NoYesPlease describeDo you take any medications related to mental health?NoYesPlease describe Please describe Do you have a preference in providers?NoYesThis does not guarantee you will be put with this providerPreviousEmailSubmit
