Intake Forms Child — English

Community Reach Center Intake Forms - Become a Patient - Woman holding pen signing agreement document

Welcome to Community Reach Center! Your first session with us is called a "New Admission" meeting. Please click on What to Expect to understand what will take place at this meeting. We offer new admission meetings on a walk-in basis, 5 days a week from 8-2pm first come, first serve.

In preparation for your first intake meeting with us, please take a few minutes to download and complete the forms below. You may find it easier to complete these forms at home where you have all your information available. However, if you are not able to print these, forms will be available when you arrive at one of our offices. Most forms are available in both English and Spanish. Please also provide a copy of your ID and insurance card (front and back for private insurance).

Please use a black ink pen to complete the form and do not fill in the date on the form until you arrive for intake.


Intake Fax Coversheet View PDF
Admission Form 
Demographic information
View PDF
Consumer Financial Form 
First page complete fully about your insurance information. 
Sign that we can release information to your insurance and you are authorizing payment. Please also provide a copy of your ID and insurance card (front and back). Carefully read the second page and keep for your records
View PDF
Proof of Income Form 
We ask for your household income to determine the amount you would pay on a sliding scale fee, if you do not have insurance or if you ever lost your insurance. We ask everyone to complete this.
View PDF
Brief Triage Form 
Describe the reason for your visit
View PDF
Medical History Form 
Medical information including your current medications and current medical provider.
View PDF
We look forward to seeing you soon!