Middle name
Preferred name (if different from above)
Guardians
This section is required if client is under 18.
Guardian
Leave blank if no guardian.
Guardian first name
Guardian last name
Guardian address
Guardian city
Guardian state
Guardian zip
Guardian phone
Guardian email
Additional guardian
Leave blank if no guardian.
Additional guardian first name
Additional guardian last name
Additional guardian address
Additional guardian city
Additional guardian state
Additional guardian zip
Additional guardian phone
Additional guardian email
Social security number
City
State AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
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MS
MO
MT
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NY
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ND
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OK
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PA
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SD
TN
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UT
VT
VA
WA
WV
WI
WY
ZIP
County
Home phone
Work phone
Mobile phone
Alternate contacts
If housing or phone is unstable, please provide additional contacts (family, friend, natural support) or locations to assist with initiating services.
Email
Preferred appointment reminder method Leave blank if client does not want to be automatically reminded of appointments. Text
Email
Race Choose all that apply.
Ethnicity Hispanic or Latino
Not Hispanic or Latino
Declined to specify
Sex
Gender identity Optional
Pronouns Optional
Marital status
Primary care physician
Name and/or office
Physician address
Physician phone
Service requested Choose a service (or leave blank)
Basic Services (Outpatient Therapy and Medication Management)
Assertive Community Treatment (ACT)
Community Support Team
Critical Time Intervention
Family-Centered Treatment
In-Home Therapy Services (Charlotte, children only)
Intensive In-Home Therapy (children only)
Peer Support- TCL Only
Substance Abuse - Basic
Substance Abuse - Intensive Outpatient
Wake Peer Recovery
Primary insurance
Insurance Choose insurance or type below
Aetna
Ambetter
BCBS
Bind Benefits Inc
Blue Medicare HMO/PPO
Cigna
First Health Network
Health Choice
IPRS
Medcost
Medicaid
Medicare
Self Pay
Tricare East
UHC Shared Services
UMR
UMR Wassau/IHR
United Health Care
UnitedHealthcare EAP
VA Fee Basis Program
Wake County Child Welfare
Wellcare HMO
Type insurance here if it isn't in the menu above.
Insurance number
Secondary insurance
Leave blank if not applicable.
Secondary insurance Choose insurance or type below
Aetna
Ambetter
BCBS
Bind Benefits Inc
Blue Medicare HMO/PPO
Cigna
First Health Network
Health Choice
IPRS
Medcost
Medicaid
Medicare
Self Pay
Tricare East
UHC Shared Services
UMR
UMR Wassau/IHR
United Health Care
UnitedHealthcare EAP
VA Fee Basis Program
Wake County Child Welfare
Wellcare HMO
Type insurance here if it isn't in the menu above.
Secondary insurance no
Preferred language with agency Arabic
Bengali
Burmese
Chinese
Dutch; Flemish
English
Persian
French
Haitian; Haitian Creole
Italian
Kanuri
Kinyarwanda
Korean
Portuguese
Pushto; Pashto
Russian
Spanish
Swahili
Tamil
Telugu
Tigrinya
Turkish
Ukrainian
Vietnamese
Declined to specify
Current medications (if known)
Allergies
Current mental health diagnosis (if known)
Has client been at a hospital, emergency room, crisis center or utilized mobile crisis for mental health symptoms in the past year? Unsure
Yes
No
Is the client currently discharging from a hospital or PRTF? Unsure
Yes
No
Has client had any previous mental health and/or substance abuse treatment? Unsure
Yes
No
Please check any of the following options that apply to the client.