Intake Form

Thank you for your interest in seeking services with Solutions. To facilitate this process, please fill out the information below and submit it electronically (see below). Please ensure that all information is completed as accurately as possible. This information will be reviewed by an Intake Specialist in order to assist in planning for the services you need. The Intake Specialist will then be in contact with you to schedule an appointment, or to provide you with referrals in the event services cannot be provided at Solutions. If you do not wish to submit this online form, you are welcome to contact an Intake Specialist by phone.

Please be advised that this form is only checked during business hours. If this is a matter that requires immediate assistance, seek emergency services in your community or call 911.

Basic Information
Where are you seeking services? *
You may select multiple locations if applicable.
Name (of new client) *
Name (of new client)
Date of Birth *
Date of Birth
Gender *
Phone *
Phone
We will use this number to contact you. Please ensure it is accurate.
How may we contact you? *
If we can contact you by phone, may we leave a message?
Please note, for privacy purposes we can only do this if your voicemail includes your name.
Address *
Address
Does the client have a legal guardian? *
Parents and guardians
This section applies only to minors or those clients with legal guardians. Please skip this section if this does not apply to you.
If client is a minor or has a legal guardian, please describe the custody situation:
Legal Guardian's Name
Legal Guardian's Name
Legal Guardian's Phone Number
Legal Guardian's Phone Number
Second Legal Guardian's Name
Second Legal Guardian's Name
Second Legal Guardian's Phone Number
Second Legal Guardian's Phone Number
Insurance and Payment Information
How will you pay for services?
If you are paying with insurance, please fill out primary insurance information
Full name as it appears on insurance card
Policy Holder Date of Birth
Policy Holder Date of Birth
Please fill out secondary insurance information if applicable
Full name as it appears on insurance card
Secondary Insurance Policy Holder Date of Birth
Secondary Insurance Policy Holder Date of Birth
Guarantor name (if applicable)
Guarantor name (if applicable)
If using a Guarantor, please identify his or her name, address, and the relationship with the client. This person would receive monthly statements if applicable. If you are not using a guarantor, please skip this section.
Additional
We can attempt to arrange for a translator, if necessary.
Acknowledgement of Electronic Submission *