Broken Not Working Intake Form (Will Remove Soon)

Intake Form
Preferred Name*
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of Birth
Current*

MonthDayYear
Date of Birth
Age*
Marital Status*
Gender*

MaleFemale
Gender Identity*
Sexual Orientation*
Emergency Contact*

NamePhone Number
Race*
Email*
Primary Contact Phone*

Area CodePhone Number
Okay to leave message?

YesNo
Serenity Location*
New Albany Therapists*
Columbus Therapists*
Westerville Therapists*
Dublin Therapists*
Serenity Therapists*
Cornerstone-Annex Academy Therapists*
Tele-Therapy Therapists*
Appointment Time Preferences:*

MorningsAfternoonsEveningsSaturdaysAnytime
Who Is the counseling for?*

ChildAdolescentAdultCoupleFamilyGroup Therapy
What is this in relation to? (select all that apply)*

Abuse/TherapyADHD/ADDAdjustment IssuesAddiction/TypeAlcohol/Substance Use/AbuseAnger ManagementAnxietyBipolarChronic Illness/Pain MgtCourt OrderedCutting/MutilationDeath/Dying IssuesDepressionDivorce/Separation IssuesDomestic ViolenceEating DisorderGrief/LossInfidelityLife TransitionsMen IssuesParentingRelationship IssuesSelf-Esteem/Self-WorthStress ManagementSuicidal Thoughts/FeelingsTrauma/PTSDDeaf/Hard of HearingTransgenderSchool IssuesBehavioral ProblemsOther
Primary Insured Member Information:
Private Pay

YesNo
EAP

YesNo
Cornerstone Academy

YesNo
Primary Health Insurance

N/AAetnaAnthemBuckeye Health PlanMedical MutualDennison UniversityOhio HealthCignaUMRMolinaCaresourceMedical MutualOptima - Ohio HealthOptum - UHCTricareMedicaidMedicareOther
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Secondary Health Insurance

N/AAetnaAnthemBuckeye Health PlanMedical MutualOhio HealthCignaUMRMolinaCaresourceMedical MutualOptima - Ohio HealthOptum - UHCTricareMedicaidMedicareOther
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Relationship to Client?*

SelfParentSpouse
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
I Authorize Serenity-BHS to check benefits on behalf of the client seeking counseling.
Member ID#*
Group #*
Provide Copy of Insurance Card

Browse Files

Cancelof
Do you Authorize?*

YesNo
Enter Initials*
Client Name*

First NameLast Name
Preferred Name*
Additional Information
Who referred you to us?*

Cornerstone AcademyHealth InsuranceEAPGoogleYelpFriendOther
Are you related to a Serenity staff member?

YesNo
Please verify that you are human*
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