Medicaid Initial Client Visit Intake Form
Complete this intake form before your initial client visit. Please provide accurate contact, visit, and coverage details so the visit can be prepared appropriately.
Client Information
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Pronouns
Please Select
She/Her
He/Him
They/Them
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Visit Details
Visit Type / Reason for Visit
Preferred Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Coverage and Support
Medicaid coverage status
*
Active
Pending
Unsure
Not enrolled
Other
Primary care provider name
Best time to contact
Morning (8am–12pm)
Afternoon (12pm–5pm)
Evening (5pm–8pm)
Weekends
Any time
Submit Intake
Should be Empty: