Child – Intake Form Name *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mobile Phone *Home PhoneEmail *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHealth InformationPhysician *PhonePsychiatristPhoneDietitianPhoneMedications and/or Supplements:Prior Mental Health Treatment:Personal InformationGuardian Name *Guardian Occupation *Second Guardian NameSecond Guardian OccupationSchool Name *Insurance InformationWE ONLY ACCEPT THE FOLLOWING INSURANCES: TRICARE, CIGNA, ANTHEM BCBS, UNITED BEHAVIORAL HEALTH, Medicaid, UMR and CHP Plus. IF YOU DO NOT QUALIFY, YOU WILL BE CHARGED ON A PER SESSION BASIS.Which is your Insurance provider? *CHARGE ME PER SESSIONTRICARECIGNAANTHEM BCBSUNITED BEHAVIORAL HEALTHMEDICAIDCHP PLUSUMROTHERPolicy Holder: *Policy Holder ID: *For all Tricare members please submit sponsor ssn not DoD numbers*Policy Holder Date of Birth: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Group NameGroup NumberReferral Source: *FINANCIAL RESPONSIBILITY AND CONSENT TO TREAT OR PROVIDE SERVICES: I understand that I am responsible for payment of services rendered at time of service. I am also giving Janice Van Anrooy, MA, LPC, permission to treat the above stated patient and to bill insurance for services rendered. I have also read and understand the HIPPA Privacy Act Information included in this intake documentation.Acknowledgments *I hereby consent to Fee Schedule and Financial PoliciesI hereby consent to Disclosure StatementI hereby consent to HIPAA PolicyGuardian(s) Signature * Clear Signature" Patient Signature (if between ages 13 and 18) * Clear Signature" WebsiteSubmit