Sign-Up Intake Form

The purpose of the Sign-Up Intake Form is to sign you up to be open to our services. The form is free to fill out but, to be provided services is either health insurance or a fee of $120 and is to be paid in person. Scheduling an appointment is at the bottom of this page.

The Sign-Up Intake Form

[A list of insurances that Acadiana Hope & Wellness accept]

First Name

Last name*

MI*

Address*

City*

State*

Zip Code*

Phone*

Work

Parent/Guardian*

Email*

May we contact you via email?*

Sex*

Male

Female

Other

Date of Birth*

Age*

Social Security *

Employer

Occupation

School

Location

Grade

Emergency Contact*

Relationship to Contact:*

Phone number of Contact*

Policy Holder Name:*

Relationship to Client*

Primary Insurance Company:*

Policy Number*

Referred by:*

Phone number of insurance*

Medication Management*

Yes

No

Maybe

Reliable transportation?*

Yes

No

Address for pick up:*

Any past mental health diagnosis?

Allergies:

Additional Presenting Problems

List the name of medications you take with the dose & frequency

Pharmacy:

Location of pharmacy*

Before you schedule, make sure your Intake form is fully completed

Payment for Scheduling is paid for in person with insurance or a payment of $120

Counselor 1

Counselor 2

Address

19157 Crowley Eunice Hwy, Crowley LA 70526

Service Desk

337-514-2101 ahwctr@gmail.com

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Acadiana Hope & Wellness Center LLC