Inquiry / Benefits Verification Form
Inquiry Date:
Client Information:
Name:
Date of Birth:
Street Address:
City, State, Zip Code:
Phone Number:
Referral Source Information:
Name:
Phone Number:
Relationship to Client:
Caller Information:
Name:
Phone Number:
Relationship to Client:
Insurance Information:
Company Name:
Type:
ID #:
Group #:
Benefit Phone Number:
If different than the Client, Policy Holder’s Name:
Street Address:
City, State, Zip Code:
History
Drug Use History:
Chemicals Used:
Amounts/Frequency/Route:
How long/Last Use:
Withdrawal/Seizure Hx:
Treatment History:
Type/When/Where:
List Treatment Episodes within the calendar year:
If currently in Tx, the current LOC:
Number of days at this LOC:
Psych History:
Diagnoses:
Psych Treatments (Type/When/Where):
Suicide Attempts:
Current Medications:
Medical Problems:
Include infectious diseases, open wounds, untreated issues, etc.:
Problem Areas:
Work/School/Legal/Relationships/Social:
Comments: