Caller’s Name: (required) Email: Relationship to client:
Client’s Name: (required) DOB Age SSN Address
What brings them in for service? Who referred you to Pacific Mind?
Policy Holder’s Name: Relationship to Client:
Policy Holder’s Address:
Insurance Company’s Address:
Insurance Company’s Phone #:
Are Behavioral Health benefits from same company? If not, which one?
Does the client have EAP benefits? If yes, do they want to use them?
EAP Provider: Authorization #
Have they contacted the EAP Provider to initiate services? If no, they must do so.
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