Phone Consult Information (intake) Form FGTC Admin to fill out phone call inquiries for new client Location: Point Loma Office Petaluma Orange County Telehealth Service Requested: Autism/RDI Mental Health Diagnosis/Assessments Person taking call: Date MM slash DD slash YYYY How did you hear about us? Client Name First Last Client Name* First Last Client/Contact Phone Client/Contact Email* Parent(s) Name Age DOB Month Day Year Reason for seeking Therapy:SDRC Client?YesNoSDRC Service Coordinator: Phone consult scheduled with: Date MM slash DD slash YYYY Time : Hours Minutes AM PM Insurance InformationInsurance Company: Plan Type (HMO, PPO, POC)Member ID: Group #: Subscriber Name Subscriber DOB Month Day Year Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone # on back of card (Provider Services or Mental/Behavioral Health): Copayment: OR Cost share/co insurance: Deductible AmountIndividual: Family: Amount MetIndividual: Family: Is parity covered? Yes No Is non-parity covered? Yes No (I)$OOP Max (I)$Met (F)$OOP Max (F)$Met Ref # Diagnosis Report Received: Assessment Requested (date): Assessment Approved: Intake Paperwork Sent:
