Intake Paperwork – LifeSpring Health Systems

Date

Patient Name*

First Last

Name of Person Completing Form (if different than patient)

First Last

Patient Date of Birth

Address (mark N/A if the patient is not housed)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your County of Residence?

Phone*

Email*

Mother’s Maiden Name

Patient's Marital Status

Patient's Race

Ethnicity

Gender Identity

Sexual Orientation

Sex at birth*

Employer or School Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Company

Insurance Policy Number

Name and Date of Birth of Policy Holder

Have you ever served in the military?

Education

Agricultural Work Status

Citizenship

Housing Status

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relationship

Referral Source*

What Service Would You Like To Schedule An Appointment For? (Select One or Both)

Please briefly describe the issue you are having or what you would like to be seen for.*

For Those Who Have Served in the Military