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It is powered by Carepatron.com and covers essential details across several sections. The Client Information section gathers personal identifiers such as first name, last name, preferred name, date of birth, marital status, address, email, and preferred phone number. It also includes fields for emergency contacts, with placeholders for their full name, relationship, and contact number, as well as patient identifiers if known. The Health and Medical Information section requests details about the primary care physician, including their address and contact number. It further asks for a list of any medical conditions and current medications the client may have. The Insurance Information section is for clients who have insurance, requiring the insurance carrier, plan name, contact number, policy number, and group number. It also includes a field for the Social Security Number. The Employment Status section allows selection from options like Self-Employed, Unemployed, Employed, or Other, with follow-up fields for occupation, industry, company name, and company address. A crucial statement of accuracy follows, asserting that all provided answers are true to the best of the client's knowledge and understanding that inaccurate information could be dangerous to their health. If applicable, a section for Parent or Guardian Name and their relationship to the patient is included. The form concludes with a signature line for the client, parent, or guardian, and a date field.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/new-client-intake-form/190084/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/new-client-intake-form/190084.png","ImageObject",442,249,{"name":88,"@type":89},"Mia  ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-03","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What personal identification details are collected in the New Client Intake Form?","Question",{"text":109,"@type":110},"The form collects first name, last name, preferred name, date of birth, marital status, address, email, and preferred phone number. It also includes fields for emergency contacts and patient identifiers if known.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What health and medical information is requested in the form?",{"text":114,"@type":110},"The form asks for the client's primary care physician's details (address and contact number), a list of any current medical conditions, and any current medications the client is taking.",{"name":116,"@type":107,"acceptedAnswer":117},"What employment and insurance details are required?",{"text":118,"@type":110},"For employment, the form asks for status (Self-Employed, Unemployed, Employed, Other), occupation, industry, company name, and address. For insurance, it requires the carrier, plan, contact number, policy number, group number, and potentially the Social Security Number.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},190084,1788400656,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":4},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","| Client Information   |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name   | Last Name   |  | Preferred Name   |  |  |  | Patient Identifier(If known)   |  |\n| Gender   | Preferred Pronouns   |  | Date of Birth   |  |  |  | Marital Status   |  |\n| Address   |  |  |  | City   |  | State   |  | Zip Code   |\n| Email   |  |  | Preferred Phone Number   |  |  |  |  |  |\n| Emergency Contact   |  |  |  |  |  |  |  |  |\n| Full Name   |  | Relationship   |  |  | Contact Number   |  |  |  |\n| Full Name   |  | Relationship   |  |  | Contact Number   |  |  |  |\n| Health and Medical Information   |  |  |  |  |  |  |  |  |\n| Primary Care Physician   |  | Address   |  |  | Contact Number   |  |  |  |\n| Please list any medical conditions   |  |  |  |  |  |  |  |  |\n| Please list any current medication   |  |  |  |  |  |  |  |  |\n| Insurance Information (If Applicable)   |  |  |  |  |  |  |  |  |\n| Insurance Carrier   |  | Insurance Plan   |  |  | Contact Number   |  |  |  |\n| Policy Number   |  | Group Number   |  |  | Social Security Number   |  |  |  |\n| Employment Status   |  |  |  |  |  |  |  |  |\n| other  \u003Cbr>OSelfEmployed  \u003Cbr>OUnemployed  \u003Cbr>OEmployed   |  |  |  |  |  |  |  |  |\n| Occupation   |  | Industry   |  |  | Company Name   |  |  |  |\n| Company Address   |  |  |  | City   |  | State   |  | Zip Code   |\n| All the answers given to the above questions are answered accurately to the best of my knowledge.I understand that  \u003Cbr>any inaccurate information can be dangerous to my(or patient's)health.   |  |  |  |  |  |  |  |  |\n| Parent or Guardian Name(If Applicable)   |  |  | Relationship to Patient(If Applicable)   |  |  |  |  |  |\n| Signature of Client,Parent or Guardian   |  |  | Date   |  |  |  |  |  |\n\nhttp://Carepatron.com  \n# New Client Intake Form\n\nPowered by","cbCaijsz5Vrm8l8j","https://ap.wps.com/l/cbCaijsz5Vrm8l8j","pdf",396269,"English","# Client Information\n## Health and Medical Information\n## Insurance Information (If Applicable)\n## Employment Status","[{\"question\":\"What personal identification details are collected in the New Client Intake Form?\",\"answer\":\"The form collects first name, last name, preferred name, date of birth, marital status, address, email, and preferred phone number. It also includes fields for emergency contacts and patient identifiers if known.\"},{\"question\":\"What health and medical information is requested in the form?\",\"answer\":\"The form asks for the client's primary care physician's details (address and contact number), a list of any current medical conditions, and any current medications the client is taking.\"},{\"question\":\"What employment and insurance details are required?\",\"answer\":\"For employment, the form asks for status (Self-Employed, Unemployed, Employed, Other), occupation, industry, company name, and address. For insurance, it requires the carrier, plan, contact number, policy number, group number, and potentially the Social Security Number.\"}]","New Client Intake Form | PDF"]