ABC Medical Clinic Form

Client Intake Form

Please Fill out this form and email it back to admin@mbcare.us or fax at 408-905-4918.

We are currently providing only tele-sessions. We are NOT able to serve EAP clients currently.

Client’s Full Name:

Client’s DOB:

Phone Number:

Email Address:

Address:

City:

State:

Zip:

Type of Service:

Individual

Couples

Family

Children

Insurance Type/Name of Insurance Carrier (Only PPO/HMO/EPO, no EAP):

Insurance ID:

Authorization if any (for HMOs):

Presenting Concerns:

Client Intake Form

Important insurance information on the next page.