Client Intake
Last Name
First Name
Middle Initial
Date of Birth
Gender
Male
Female
SSN
Street Address
City
State
ZIP
County
Email Address
May we send you information at this email?
Yes
No
Do you currently reside in a:
Private Residence
Residential program
Assisted Living facility
Group Home
Nursing Home
Hospital
Home Phone
May we text, call, or leave a message at this #?
Yes
No
Cell Phone
May we text, call, or leave a message at this #?
Yes
No
Work Phone
May we text, call, or leave a message at this #?
Yes
No
Insured’s Date of Birth:
Primary Insurance
Insured's Name
Secondary Insurance
Secondary Insured's Name
Secondary Insured’s Date of Birth:
Briefly describe what brings you to Vine Health Care
Referral for:
Mental Health
Private Duty Aide
Medication Management
Private Nurse
Referred by:
Self
Hospital
Family/Friend
School
Court
Physician
DHS
Probation Officer
Other
Name of referral (If applicable DHS contact probation officer doctor)
Requirements: (please provide documentation):
None
Guardianship
Power of Attorney
Conservatorship
Employment
Full time
Part time
Unemployed/looking for work
Student
Retired
Disabled
Other
Employer
Occupation
Address:
Guardian/Cons./POA Name
Guardian/Cons./POA Phone
Guardian/Cons./POA Address
Emergency Contact
Relationship to Client
Emergency Phone
I give consent to contact the above listed person in the event of an emergency
Yes
No
Marital Status
Never Married
Married
Divorced
Widowed
Separated
Ethnicity
White/Caucasian
African American
Hispanic
American Indian
Asian/Pacific Islander
Other
FAMILY/HOME INFORMATION
How many people live in your home? (Include yourself)
Name
Age
Living at Home?
Yes
No
+ Add
MEDICAL/HEALTH INFORMATION
Have you received mental health treatment before?
Yes
No
If yes, Where
When
Do you use: Tobacco? Alcohol? Drugs?
Have you been treated for alcohol/drug problems before?
Yes
No
If yes, Where
When
It is very important for your therapy and medication management at Vine Healthcare that we are able to have contact with your primary care provider (PCP). Do you give your permission for us to contact your PCP?
Yes
No
If you decline, please provide specific reason for your denial
Who is your primary doctor/medical provider?
Name
City
Phone Number
Which pharmacy do you use?
Phone
Please list any current or ongoing medical problems:
What medications do you take? (Include non-prescription, herbal medicines and supplements)
Medicine
Dose
Frequency
Who prescribes
+ Add
Please list any allergies, including medication allergies/sensitivities:
Client/Guardian Signature:
Clear
Date
Witnessed By:
Submit
