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Our Clinic
Services
Schedule An Assessment
New Patients
Contact us
HIGHTOWER BEHAVIORAL HEALTH PATIENT INTAKE FORM
Patient Name: (First & Last)
Middle Name
Date of Birth
Social Security Number
Sex
Home Address:
City
State
Zip Code
Home #
Cell #
Work #
Email Address
Preferred method of contact
Phone
Email
Letter
Marital Status
Married
Single
Divorced
Separated
Widowed
Language (other than English)
Race
Ethnicity
Employer
Spouse/Parent
Phone #
Emergency Contact
Phone #
How did you hear about us?
Ins Co Name
Pollicy/ Member ID #
Patient Relation to Insured
Self
Self
Spouse
Spouse
Child
Child
Other
Other
Policy Holder
Sex
Address
City
Zip Code
Home #
Date of Birth
Employer
Ins Co Name
Policy/ Member ID #
Patient Relation to Insured
Self
Self
Spouse
Spouse
Child
Child
Other
Other
Policy Holder
Sex
Address
City
Zip Code
Home #
Date of Birth
Employer
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