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Address

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Insurance Insurance Aetna Anthem Blue Cross Blue Shield Carelon Behavioral Health Cigna Humana Quest Behavioral Health Optum Oscar Oxford United Healthcare Other Self-Pay

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What concerns led you to seeking treatment?

Is this the first time seeking treatment? Is this the first time seeking treatment? Yes No

Substance Abuse History (check all that apply) Substance Abuse History (check all that apply) Alcohol Marijuana Cocaine Opiods (Heroin, Fentanyl, pills) Benzodiazepines Amphetamines Other

Frequency of use Frequency of use Daily Weekly Binge/Intermittent Abstinent

Date of last use

Have you ever been diagnosed with mental health diagnosis? (If yes, please specify)

By submitting this form I acknowledge that this form is not a crisis service, Submission does not establish a therapist=client relationship, and information provided is accurate to the best of my knowledge By submitting this form I acknowledge that this form is not a crisis service, Submission does not establish a therapist=client relationship, and information provided is accurate to the best of my knowledge I agree