VMOS Client Portal | New Client Intake

General Information

Client:

Last Name

First Name

Preferred Name

Date of Birth:

Date

Age

Sex:

Male

Female

Intersex

Prefer Not to Say

Address:

Mailing

City

State

Zip Code

How/from whom did you hear about ABT?

Organization/Person Name (if applicable)

Communication Information

Occasionally, it will be necessary for our office to contact you regarding matters about counseling. This permission form will help us know when and how to contact you in ways which are comfortable for you.

By giving permission for use to contact you in one or more of the ways listed below, you are agreeing for us to leave messages and information. We will always try to be discreet in any messages we leave, but we cannot guarantee confidentiality once the message is left.

Phone Numbers:

Cell

Home

Work

Preferred Contact

Email Address:

Primary Email

In order for you to get access to our Client Portal we must have an email.

Depending on the type of Reminders you select below, we need a cell phone and/or an email.

Appointment Reminders:

No Reminders

Email Only

Text Only

Both Email & Text

Reminder Frequency:

48 Hours

24 Hours

48 & 24 Hours

48 & 2 Hours

24 & 2 Hours

Parent/Legal Guardian Information

Responsible Party:

Full Name

Relationship

Insurance Information

Insurance Type:

Commercial Medicaid Self-Pay

Is the client the policy holder?

Do you have a secondary insurance?

Is this being covered by an EAP?

Insurance Company Name:

Employer:

Member ID:

Group Number:

Phone Numbers:

Customer Service/EAP

Mental Health

EAP:

Authorization #

# of Visits

Start Date

End Date

Secondary Insurance Type:

Commercial Medicaid

Secondary Insurance Company Name:

Employer:

Member ID:

Group Number:

Policy Holder's Full Name:

Date of Birth:

Relation:

Please provide a brief reason why the client is seeking counseling?
Please try to limit to 150 words or less.

Therapist or Clinician Information

Please answer the following to help us get you scheduled:

What gender would you prefer for your therapist or clinician?

Male

Female

No Preference

Is there a specific therapist or clinician you would like to see?

Is there a specific location you would prefer?

Blacksburg

Daleville

Floyd

Roanoke

Salem

What time of day would work best for you?

Morning

Afternoon

Evening

Anytime

Are there specific dates/time you would like us to look at?

Which way would you like us to contact you about your appointment?

Phone

Text