Intake Form

BEHAVIORAL HEALTH INTAKE REQUESTS

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Adult Outpatient

Name

Birthdate

Zip Code

Had Insurance?

Insurance Type

Medicaid/Insurance ID Number

Best Call Back Number *

Best Call Back Time

Preferred Language

Child & Adolescent (C&A)

Name

Child's Name

School Name

Child's Birthdate

Zip Code

Had Insurance?

Insurance Type

Medicaid/Insurance ID Number

Best Call Back Number *

Best Call Back Time

Preferred Language

Household Size	1	2	3	4	5	6	7	8
30 Day Gross Income	$2,265	$3,052	$3,838	$4,625	$5,412	$6,198	$6,985	$7,324

BEHAVIORAL HEALTH INTAKE REQUESTS

Adult Outpatient

Child & Adolescent (C&A)

GEC Services

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Income Guidelines

LIHEAP ELIGIBILITY REQUIREMENTS