New Client Intake

Divine Healing Behavioral Health

1 Basics 2 Contacts 3 History 4 Safety 5 Consents

Privacy note: This form is for requesting services and collecting pre-intake information. If you’re experiencing a medical emergency or danger, call 911 or go to your nearest ER.

Basic Information

Please complete required items so we can contact you quickly.

Full Legal Name

Preferred Name

Date of Birth

Phone

Preferred Contact

Address

Reason for Visit (short)

Emergency & Contacts

Used only if needed for safety/coordination.

Emergency Contact Name

Relationship

Emergency Phone

Primary Care Physician (optional)

Insurance Provider (optional)

Member ID (optional)

Group # (optional)

Behavioral Health History

This helps match you with the right provider.

Current Concerns

Prior Counseling / Therapy

Current Medications (optional)

Medical Conditions (optional)

Substance Use (optional)

Safety & Crisis Screening

Answer honestly. This helps us respond appropriately.

Are you in immediate danger right now?

If Yes, please call 911 or go to the nearest emergency room.

In the last 30 days, have you had thoughts of harming yourself?

In the last 30 days, have you had thoughts of harming someone else?

Anything we should know for safety (optional)

Consents & Acknowledgments

These acknowledgments are common in clinical intake workflows.

I understand this is a pre-intake request and not a guarantee of services. I understand clinic staff may contact me using the information provided.

I acknowledge receipt/availability of the clinic’s privacy practices (HIPAA Notice of Privacy Practices) and understand my information is protected.

I consent to communication by email/text for scheduling and administrative purposes (not for emergencies).

Preferred Appointment Type

Typed Signature (full name)

Signature Date

Relationship (if not self)

Additional Notes (optional)

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By submitting this form you consent to be contacted by Divine Healing Behavioral Health regarding services or scheduling. Information is protected under HIPAA guidelines.