Join Us – Community Action Initiative Inc

Community Action Initiative Inc

Are you the patient?Yes (I am the patient)No (I am not the patient)

If you are not the patient, are you the patient's…..Legal GuardianFamily MemberReferral Source

Age of Patient:

State:

Patient's First Name *

Patient's Last Name

Patient's Preferred Name (optional) *

Patient's Birth Date

Patient's Primary Language

Patient's Gender

Patient's Email *

Patient's Mobile Phone

Service RequestedTherapyMental HealthSubstance UseEating Disorders

–Mandated Services including Child Protective ServicesParenting ClassesDomestic Violence ServicesAnger Management Services

Is the patient currently covered by any health insurance plans?YesNo

Insurance Type

Primary Insurance Carrier

Insurance ID #

Plan ID

Policy Holder Name

Secondary Insurance Carrier

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