1-844-SPIN-CAN • 10501 Drummond Rd. Phila., PA 19154

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BH Intake

IDENTIFIED CLIENT DEMOGRAPHIC INFORMATION

Name:*
Age:*
D.O.B.:*
Gender identified at birth:*
Primary Insurance Plan Name: *
If Other, Plan Name:
Member ID #
Secondary Insurance Plan Name:
If Other, Secondary Plan Name:
Secondary Member ID #

Please be prepared to send us a copy of your insurance cards.

LEGAL GUARDIAN DEMOGRAPHIC INFORMATION

Legal Guardian Name:
Legal Guardian D.O.B.:
Primary Contact #: *
-
E-mail Address:*
Primary Language:*
Interpreter Needed: *
Legal Guardian Address:

If the client’s biological parent(s) and/or court appointment legal guardian(s) is not present at the time of the appointment, the appointment will need to be cancelled and rescheduled. All legal custody/guardianship paperwork must be sent prior to the scheduled appointment via fax or mail (must bring proof of custody if living with person(s) other than biological Parent(s). Proof must state that the person providing treatment consent and attending appointments has LEGAL rights of the child).

Is there a custody agreement or court order agreement?:*
Is DHS involved?:*
Name of DHS Worker:
Does the client have an assigned CUA worker?*
Name of CUA Worker:

SERVICE HISTORY

Does the client have an Autism Diagnosis?*
Has the client received Behavioral Health services at SPIN? *
Has the client received Pre-School services at SPIN?:*
Does the client currently take any type of Psychiatric Medication?:*
Other agencies/services currently receiving:
REASON FOR REFERRAL:*
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