Admission Form | Genesis Behavioral Health Services

Is Client an Adolescent? *

Client’s Name *

Client's Date of Birth *

Main Reason Seeking this Level of Care *

Client’s Allergies *

Parent/Legal Guardian’s Name *

Custody Status *

Parent/Legal Guardian’s Email *

Parent/Legal Guardian’s Phone Number *

Address *

Name of Insurance *

A. Subscriber Name *

B. Subscriber Date of Birth *

C. Subscriber Address *

D. Subscriber Telephone Number *

E. Policy Number *

F. Group Number *

G. Employer *

Referral source *

Front of Insurance Card *

Back of Insurance Card *

Admission Intake Form