Pathway Healthcare Intake Form

1

Let's get started!* This field is required.Which option best describes you?

Referring ProviderNew Patient

2

Patient Info:* This field is required.

First Name

Last Name

Email Address

Phone Number

Zipcode

Preferred Method of Contact

3

Patient Date of Birth* This field is required.

Date

4

Will insurance be used?* This field is required.Hit next if you are unsure.

YESNO

5

Are you able to upload an current insurance card picture?

YESNO

6

Terms and Conditions* This field is required.Please agree to our T&Cs and sign before uploading

7

Signature* This field is required.Signing below means you agree to provide this sensitive information

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8

Upload Picture* This field is required.Please provide a clear front and back picture of insurance card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

9

Name of insurance being used?* This field is required.

10

Member IDHit next if you are unsure.

11

Payer IDHit next if you are unsure.

12

What services are required?* This field is required.Choose all that apply

Intensive Outpatient Treatment

Psychiatry

Treatment for Substance Use Disorder

Individual Therapy

Family Therapy

Group Therapy

13

Would you consider telehealth?* This field is required.

YESNO

15

Referral Info:* This field is required.We want to say thank you!

First Name

Last Name

Email Address

Phone Number

Referring Facility

How did you hear about us?