BCT, Inc.

Intake Form (MAIL or FAX)

(PLEASE PRINT)

Your Name : _______________________________________________________________________

Address: __________________________________________________________________________

City: ______________________________________  State: __________________________ Zip: __________________

E-Mail: __________________________________________________

Home Phone: (_____) __________________

Work Phone: (_____) __________________

Cell Phone: (_____) __________________

Today's Date: ____ / ____ / ____

• Who are you seeking services for?

__________________________________________________________

• What is your relationship to this person?

__________________________________________________________

• Date of Birth of potential client: ____ / ____ / ____

• Your Marital Status?

__________________________________________________________

• If you are a parent seeking treatment or evaluation for

a child and are divorced or separated from the child's other

parent, please answer the following questions:

* Who has legal custody of the child? ________________________________

* Is there currently, or do you anticipate a legal battle over custody, visitation, or anything related to

the child?   Yes   No

• Who is the potential client's primary care physician?

__________________________________________________________

• Where are they located?

__________________________________________________________

• Who, if anyone, referred you to our practice?

__________________________________________________________

• Do we have your permission to thank the person who referred you?

__________________________________________________________

• Do you plan to use your health insurance to pay for our

services ?

( ) Yes.

( ) No.

• If so, what type of health insurance do you have? __________________________________________________

• Subscriber's name?  __________________________________________________________

• Insurance Identification number? ________________________________

• Insurance telephone number for mental health benefits? (_____) __________________

• Please briefly describe the nature of the problem you are seeking services for.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

• What type of services are you seeking? Check all that apply.

( ) Unsure. Would like evaluation and recommendations for services.

( ) Individual Psychotherapy

( ) Family Therapy

( ) Hypnosis/Hypnotherapy

( ) Group Therapy, Which group? ______________________ 

( ) Psychological Evaluation

( ) Mediation

( ) Consultation

( ) Developmental Evaluation

( ) Psycho-educational Testing

( ) Other, please specify:

__________________________________________________________

• Do we have permission to leave a general message on your answering machine at home? At Work?

( ) Yes.

( ) No.

• When would you be able for services on a regular basis?  Obtaining services after 3 P.M. on weekdays are

difficult given the high demand. Please be sure to check all that apply:

( ) Anytime.

Tuesdays           ( ) 10:30-12      ( ) 12-2 P.M.     ( ) 3-6 P.M.    

Wednesdays ( )  10:30-12     ( ) 12-2 P.M.     ( ) 3-6 P.M.     ( ) after 6 P.M.  

Thursdays   ( ) 10:30-12      ( ) 12-2 P.M.     ( ) 3-6 P.M.     ( ) after 6 P.M. 

Fridays        ( ) 10:30-12     ( ) 12-2 P.M.      ( ) 3-6 P.M.   

    

Please print out this form and fax it to us at 918-632-0065, or mail it to:

BCT, Inc

6130 E. 32nd St.

Suite 101

Tulsa, OK  74135-5454

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