Healing Transition Behavioral Health Services

Clinical Intake Form

Please complete this form as fully and accurately as possible. The information you provide helps us understand your needs and determine the most appropriate behavioral health services. All information is kept strictly confidential in accordance with HIPAA and applicable state and federal laws.

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Thank you for your response. ✨

Section 1

Personal Information

Full Name (First, Last)

Date of Birth (YYYY-MM-DD)

Gender Identity

Pronouns (optional)

Race / Ethnicity

Preferred Language

Phone Number

Email Address

Mailing Address – Street

Mailing Address – City

Mailing Address – State

Mailing Address – ZIP

Section 2

Emergency Contact

Emergency Contact Name

Relationship to You

Emergency Contact Phone Number

Section 3

Insurance & Referral Information

Insurance Provider

Member ID / Policy Number

Group Number

Referring Provider / Agency Name

Referring Provider / Agency Contact Number

Reason for Referral

Section 4

Presenting Concerns

Primary reason for seeking services

How long have you been experiencing these concerns?

Section 5

Mental Health & Treatment History

Previous mental health treatment?

If yes, provider name

If yes, dates of treatment

If yes, type of treatment

Current medications (name, dose, and frequency if known)

Prior hospitalizations or crisis episodes

Section 6

Substance Use History

Current or past substance use?

Substances used

Frequency of use

Date of last use

Previous substance use treatment

Section 7

Legal History

Current court or probation involvement?

If yes, case type

If yes, supervising officer name and contact

Section 8

Social & Environmental Factors

These questions help us provide holistic, wrap-around support tailored to your full life situation.

Housing

Current living situation

Are you concerned about losing your housing?

Food Security

In the past 30 days, have you worried about having enough food?

Employment

Employment status

Are you interested in employment support?

Education

Highest level of education completed

Financial Strain

In the past year, have you had difficulty paying bills or meeting basic needs?