Patient Application There was an error trying to submit your form. Please try again. Legal Name This field is required. Date of Birth This field is required. Gender Select an option Male Female Other Address Address Line 1 This field is required. Address Line 2 This field is required. City This field is required. State This field is required. Postal Code This field is required. Country Select an option Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of the Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Persian Gulf Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea Korea, Republic of South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Reunion Saint Barthelemy Saint Helena, Ascension and Tristan Da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Yemen Zambia Zimbabwe Phone Number This field is required. Email This field is required. Referral Information Referring Agency / Attorney / Court This field is required. Referral Contact Person This field is required. Phone Number This field is required. Email This field is required. Reason for Referral (check all that apply) Substance Abuse Evaluation Pre-Sentencing Investigation Report Family Court Mitigation Report Pre-Incarceration Services Other If Other is Checked, Describe below This field is required. Consent to Release Information I, (Client Name) Client Name This field is required. hereby authorize Bellamy & Associates and its licensed clinicians to release and/or obtain information regarding my assessment, evaluation results, and/or treatment recommendations to/from the following individual(s) or entity(ies): Referring Attorney This field is required. Court/Probation Officer This field is required. Other (Specify) This field is required. I understand that This information will be used solely for legal, diagnostic, or treatment purposes. I may revoke this consent in writing at any time, except to the extent that information has already been released. This authorization will remain valid for one year from the date signed, unless otherwise specified. Client Signature This field is required. Date This field is required. Printed Name This field is required. Date This field is required. Clinician/Witness Signature This field is required. Date This field is required. Acknowledgment & Signature I certify that the information provided in this intake packet is true and accurate to the best of my knowledge. Client Signature This field is required. Date This field is required. Clinician/Witness Signature This field is required. Date This field is required. Submit There was an error trying to submit your form. Please try again.
