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Integrated Health & Behavior, PLLC

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Intake Questins

Intake Questions

If you have not already contacted the office, please call 509-891-7867 before completing this form.
This form does not have any identifying information besides your birthday.
Thank you for taking the time to fill out the information below.

Birthday

Reason for appointment:

Current Diagnosis

Current Medications and Perscribing Doctor:

Who referred you to us?

Who is your primary care Doctor?

If you have seen a psychiatrist or therapist in the past, who did you see?

We have therapists on site. Would you be willing to see our counselors?

Yes

No

We do NOT bill for EAP visits. By checking this box I certify that this is not going to be billed through EAP.

If you become a patient with us, you consent to allow us to access your last 12 months of perscription history.

Yes

No

Integrated Health and Behavior, PLLC

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