intake-general – I-View Mental Health

Start your journey

First Name

Last Name

Gender

Male Female Non-Binary Other

Phone

Street Address

City

Zip Code

Date of Birth

Services Requested

Medication Management Therapy

Insurance Company

Insurance Member ID

Insurance Subscriber's Name

Insurance Subscriber's Date of Birth

Photo of Insurance Card (Optional)

Secondary Insurance Company

Secondary Insurance Subscriber's Name

Secondary Insurance Subscriber's Date of Birth

Secondary Insurance Member ID

Current Diagnosis or Presenting Problem

Current Medications

Treatment History

Emergency Contact

Emergency Contact Number

Preferred Pharmacy

Allergies

Did an agency refer you to us?

Please allow 2-3 business days for us to process your intake form. Once complete, we will call to schedule your first appointment.