Forms

Client Intake Instructions

How Do I Become A Client?

Step 1 – Complete the Eligibility Confirmation and Enrollment Forms:

  1. Please complete the Pre-Admission Questionnaire on the following pages to confirm eligibility for our services.
  2. After you submit the Eligibility Questionnaire, we will be in touch with you to complete the required forms:

New Client Intake Packet – This form includes all of our policies and consents.

You will need to provide:

  1. Photo of a valid state-issued ID/Passport (if the client is a minor, please provide the ID of the parent/guardian)
  2. Photos of the front and back of your insurance cards
  3. Photo of your prescription card (if you have one)
  4. if you have trouble uploading images of your ID, Insurance, or Prescription card, you may email copies to intake@momentum-cares.com

New Client Release of Information

You will need to provide:

Emergency contacts (if you do not want your emergency contacts to have access to your health information, please select “Emergency Contact Only” in the Information to be Released section)

  1. Primary Care Physician information
  2. Insurance Provider contact information, for billing purposes

Step 2 – Schedule Your Intake Appointment:

  1. After receiving and verifying your intake paperwork, an Administrative Assistant will contact you to schedule your initial appointment with an Intake Specialist. This is a one-time appointment intended to gather information so that you can be matched with a therapist.
  2. On the day of your appointment, you will receive an email with a link to start your Intake Appointment. Please check your regular inbox and spam folders for an email from the Intake Specialist that is completing your Intake Appointment. Click on the link in the email and follow the prompts and instructions to get connected with the Intake Specialist.