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2435 Kimberly Road, 165S Bettendorf, IA 52722 563.232.1878 563.232.1879 (fax)www.flahertycounseling.comtina@flahertycounseling.comHello and welcome! I look forward to meeting you at your first appointment!

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How to fill out adult intake form

01

Step 1: Start by gathering all the necessary information and documents required to fill out the adult intake form.

02

Step 2: Begin filling out the personal information section, including your full name, date of birth, address, and contact details.

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Step 3: Move on to the medical history section, providing accurate and relevant information about your past and current medical conditions, medications, and allergies.

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Step 4: Complete the section related to lifestyle habits, such as smoking, alcohol consumption, and exercise routines.

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Step 5: If applicable, fill out the section regarding any known family medical history.

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Step 6: Review the entire form once completed, ensuring all information is accurate and legible.

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Step 7: Sign and date the form where indicated to certify the accuracy of the provided information.

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Step 8: Submit the filled-out adult intake form to the relevant healthcare provider, either in person or through the designated submission method.

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Step 9: Retain a copy of the form for your personal records.

Who needs adult intake form?

01

Adult intake forms are typically required by healthcare providers when a person reaches the age of 18 or older. It is necessary for any adult seeking medical treatment, whether for routine check-ups, specific health concerns, or emergency situations. The form helps the healthcare provider gather essential information about the individual's medical history, lifestyle habits, and overall health status, facilitating proper diagnosis, treatment, and care.

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What is adult intake form?

An adult intake form is a document used to collect personal, medical, and background information from individuals entering a program or receiving services, often in healthcare or counseling settings.

Who is required to file adult intake form?

Individuals seeking treatment, services, or participation in programs that require personal and medical history are required to file an adult intake form.

How to fill out adult intake form?

To fill out an adult intake form, individuals should provide accurate and comprehensive information as requested, including personal details, medical history, and any specific questions related to the services they are seeking.

What is the purpose of adult intake form?

The purpose of the adult intake form is to gather necessary information to assess the individual's needs, create a tailored plan for treatment or services, and ensure safety and appropriateness of care.

What information must be reported on adult intake form?

Typically, the adult intake form must report personal identification information, contact details, medical history, current medications, allergies, mental health status, and any insurance information.

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