Client Intake Form | Visit Health Recovery

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Client Intake Form

Submit a client intake form below. Fields marked with an asterisk (*) are required. All information is kept secure and strictly confidential.

Referral DETAILS:

Name of Individual/ Agency Referring Client

Individual/Agency Phone Number

Contact Email

Client DETAILS:

Client's Name

Client's Phone Number

Client's Date of Birth

Sex

Male

Female

Is client pregnant?

Yes

No

Street Address

City

State

Apt./Ste. #

ZIP

Insurance Company

Insurance Type

ID#

Group #

Drug & Alcohol Use History

Date of Last Use

Length of Use

Amount Used

Detox History / Prior Treatment

Thanks for submitting!
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inquiries@visithealth.com

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