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Client Intake Forms

Client-intakeform-

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  • WELCOME to the New Client Intake Forms Section:



    The following collection of forms is meant to gather your information so that we may enter you into our electronic health records (EHR) system called TherapyNotes. All of your protected health information (PHI) is encrypted and kept secure throughout this process.

    This first form below is for Targeted Case Management (TCM) — TCM assists with social needs such as food, housing, transportation, SSDI, educational & employment goals & more.

    TCM is for Medicaid recipients only — this includes Passport, WellCare, Anthem, Aetna, and Humana.

    If you do not wish to enroll in this free service, please scroll to the bottom of this form and hit the “next” button. This is the only form that is optional, please fill out and/or read over all other forms and sign them. Thanks!

  • Targeted Case Management

  • What to expect

    You will be contacted by your case manager within 48-hours, and they will meet you twice a month in order to help you complete your needs and goals.
  • Date Format: MM slash DD slash YYYY
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