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Group Therapy Intake Form

Telehealth only

Please Check to join Navigating sobriety group.

Please Check to join Emotional Wellness: Anxiety and Depression group

First name*

Last name*

Preferred Name/Pronoun

Date of Birth*

Month

Day

Year

Age*

Sex ( for insurance purpose only)*

Phone Number*

Secondary Phone

Email*

Address Type*

Street*

Apt Number

City

State

Zip Code

Referral Source *

How did you hear about us?*

Are you Insured?*

Yes

No

Following Insurances*

Are you in individual therapy currently?*

Yes

No

Description of Problem:*

Mental Health Diagnoses

Have you ever been diagnosed with any mental health disorders?*

Yes

No

Mental Health Diagnoses Description:

Current or Past Mental Health Providers?

Yes

No

Current Medications?

Please list all prescribed medications you are currently taking (esp those for mood, energy, mental, behavior, etc). Please list or type NONE *

Substances Use History*

Areas You Want to Improve?

Your Goals for Joining Support Group?

POLICY HOLDER

First Name*

Last Name*

Date of Birth*

Month

Day

Year

IF YOU ARE NOT THE SUBSCRIBER OF THE INSURANCE POLICY PLEASE ENTER THE SUBSCRIBERS INFROMATION

Insurance Number

Insurance Type*

I attest that all of the above information is true and accurate to the best of my knowledge.*

150 Grossman Dr. Suite 205, Braintree, MA 02184

508-838-1940 admin@morsewood.com

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