Cognitive Hygiene Advanced Therapy

Client Intake Form

Today's Date

Screening Questions

Has the client received a mental health evaluation?

Yes

No

I'm not sure

Has the client been diagnosed with a mental health disorder?

Yes

No

I'm not sure

Does the client currently have medical insurance?

Yes

No

I'm not sure

Does the client have insurance coverage with one of the following? If so, please select the corresponding insurance company. If none of the these apply, select none.