Client Intake — Ellis Michael Healthcare Services

Step 1 of 6

About You

Your First Name *

Required

Your Last Name *

Required

Street Address *

Required

City *

Required

State *

Required

Zip Code *

Required

Your Date of Birth *

Required

Your Phone Number *

Required

When would you like to start? *

Required

Step 2 of 6

Your Schedule

Which days would you like to attend? *

Please select at least one day

Step 3 of 6

Your Financial Information

This information is needed for direct deposit setup and is kept confidential by our payroll team.

Your Social Security Number *

Required

Your Bank Routing Number *

Required

Your Account Number *

Required

Step 4 of 6

Your Emergency Contact

Contact Name *

Required

Contact Phone *

Required

Their Relationship to You

Step 5 of 6

Your Health Information

What medications do you take between 9am–2pm? *

Required

Do you have any allergies? *

Required

Your Preferred Hospital *

Required

Your Dentist

Your Doctor

Any diagnoses or conditions we should know about?

Step 6 of 6

Tell Us More About You

What kinds of things upset you? *

Required

What helps you feel calm or safe? *

Required

What do you enjoy doing?

Anything else you'd like us to know?

✓

All Done!

Thank you for filling this out. Our team will review your information and reach out to get everything set up for you.

Client Intake Form

All Done!

Ellis Michael HCS