INTAKE FORM

Click on the links below to download the intake forms. Please complete these and bring with you to your first visit. The forms can be downloaded in either Microsoft Word format (MS Word) or in Adobe Acrobat format (PDF).

If you are not able to download and print these forms, please arrive at least 10 minutes early to fill out the intake forms in the office.

Before scheduling, call your insurance company and ask if Sandi Black is on your particular MENTAL OR BEHAVIORAL  HEALTH PLAN.  Ask what your copay will be.  Ask if you have met your deductible (if you have one)  If you are using an EAP, be sure to let KACI (my scheduler) at 817-292-3527, know when you first call.  Be sure to give her the authorization number.  Otherwise your company or insurance will not pay for that session.

BE SURE TO READ THE CREDIT CARD GUARANTEE FORM CAREFULLY, FILL IT OUT AND BRING IT WITH YOU TO YOUR FIRST VISIT.  IT WILL BE KEPT IN YOUR CONFIDENTIAL FOLDER.

 

Intake form page 1 (MS Word)

Intake form page 2 MS Word)

Intake form page 1 (PDF)

Intake form page 2 (PDF)

Credit card guarantee for possible deposit and remaining balance (MS WORD)