top of page
Intake Form
Insurance Company
What is your gender?
Is this a cell phone?
Can we contact you on social media?
Do you have a Primary Care Physician?
Would you like us to make a referral to WISH clinic in Henrietta?
Do you have a past/active substance use history?
Do you have a care manager?
Have you been contacted by a care manager?
Would you like us to make a referral to a HCBS Yes Provider?
What services are you interested in?
Did the Client sign a Release form?
bottom of page