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Home / Services / Behavioral Health Services / Health Forms / Counseling Intake Form

Counseling Intake Form

To be Completed by the individual seeking services ONLY

Counseling services can be acquired by filling out the form below or by calling the bilingual intake line at 508-693-7900 ext 290. Portuguese-speaking clients may call Geany Rolanti at 508-693-7900 Ext 225 for assistance.

"*" indicates required fields

Δ

Date*

Name*

First Last

Date of Birth*

Phone*

Email*

Billing Address*

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

Physical Address (if different than Billing)

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

Do you have a Legal Guardian?

Yes

No

Legal Guardian Name*

First Last

Relationship to Legal Guardian*

Legal Guardian Date of Birth

Legal Guardian Phone*

Legal Guardian Email

Legal Guardian Address

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

Legal Guardian #2 (if applicable)

First Last

Relationship to Legal Guardian #2

Legal Guardian #2 Date of Birth

Legal Guardian #2 Phone

Legal Guardian #2 Email

Legal Guardian #2 Address

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

Special Communications/Needs:

None

TTD/TTY device

Sign Language Interpreter

Assistive Listening Device(s)

Language Interpreter Services Needed/ Other Spoken Language

Special Physical Accommodations:

Ethnicity:

African American

American Indian/Alaskan

Asian

Caucasian

Hispanic

Multiracial

Native Hawaiian/Pacific Islander

Unknown

Primary Payor/Insurance Information*

No Insurance

Self Pay

Co Pay

Policy Holder Insurance Company Name*

Insurance Policy Number

Insurance Group Number

Policy Holder Name

First Last

Policy Holder Date of Birth

Policy Holder Employer

Policy Holder Address

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

Secondary Insurance: Policy Holder Insurance Company Name

Secondary Insurance: Policy Number

Secondary Insurance: Group Number

What has caused you/this person to seek services at this time?*

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"*" indicates required fields

Δ

URL

This field is for validation purposes and should be left unchanged.

Email Address:*

Name

First Last

Martha's Vineyard Community Services enhances the lives of Islanders from every corner of the Vineyard community and in every season of their lives.

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