Counseling Intake Form | Martha’s Vineyard Community Services

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?

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:

Special Physical Accommodations:

Ethnicity:

Primary Payor/Insurance Information*

Policy holder Insurance Company Name*

Insurance Policy Number

Insurance Group Number

Police 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?