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
Gender Identity
Sexual Orientation
Emergency Contact

NamePhone Number
Race
Email
Primary Contact Phone

Area CodePhone Number
Okay to leave message?
Serenity Location
New Albany Therapists
Columbus Therapists
Westerville Therapists
Dublin Therapists
Serenity Therapists
Cornerstone-Annex Academy Therapists
Tele-Therapy Therapists
Appointment Time Preferences:
Who Is the counseling for?
What is this in relation to? (select all that apply)

Other
Primary Insured Member Information:
Private Pay
EAP
Cornerstone Academy
Primary Health Insurance

Other
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Secondary Health Insurance

Other
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Relationship to Client?
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?
Enter Initials
Client Name

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

Other
Are you related to a Serenity staff member?
Please verify that you are human
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