Client Intake Form

Services
Therapists
Intake Form
Insurances

Services
Therapists
Intake Form
Insurances

Client Intake Form

Please Note: Village Therapy Group is affiliated with HEADWAY as our
billing and payment service. By providing your insurance information you
are consenting to insurance verification through HEADWAY.

Client Intake Form

Full Name *

Date of Birth *

Email *

Phone *

Street Address *

City *

State *

Zip Code *

Reason for seeking therapy *

Symptoms *

Depression

Anxiety

Crying spells

Racing thoughts

Sleep pattern disturbance

Change in appetite

Hallucinations

Fatigue

Excessive worry

Avoidance

Loss of interest

Impulsivity

ADHD

ADD

Other

Insurance Company *

Subscriber ID # *

Group Number - No Dashes

Insurance Policyholder Full Name *

Insurance Policyholder Date of Birth

Insurance Company Phone Number

Secondary Insurance Company ID #

Secondary Provider Contact Number

Emergency Contact

Emergency Contact Phone Number

Email

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If you are human, leave this field blank.

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