Demographics (4/4)

Demographics Questionnaire
intake_id*
Identifier for intake flow: {FirstName_|_Email}
Email*
example@example.com
Name*

First NameLast Name
Marital Status

MarriedSingleDivorcedSeparatedWidowed
Sex assigned at birth:

MaleFemaleIntersexPrefer Not To Answer
Sexual Orientation

Straight (heterosexual)Gay/Lesbian (homosexual)BisexualPrefer not to sayOther
Gender Identity

Cisgender (aligns with sex assigned at birth)Transgender (differs from sex assigned at birth)NonbinaryPrefer not to sayOther
Race (select all that apply)

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteDecline to SpecifyOther
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoDecline to Specify
Language Fluency
Please enter the language(s) that you are fluent in
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.
Financial Information
Who will be financially responsible for you?

MyselfSomeone Else
Responsible Party Name

First NameLast Name
Responsible Party Phone Number
Please enter a valid phone number.
Primary Insurance Member/Subscriber ID#
If not applicable, you may skip to the next field
Secondary Insurance Member/Subscriber ID#
If not applicable, you may skip to the next field
How did you hear about us?

Google SearchReferred by my doctor, therapist, or other clinicianInsurance Website/ListingZocDocPsychology TodaySocial MediaWord of Mouth
Credit Card Authorization

The information below is to be completed by the cardholder. The undersigned agrees and authorizes Heading Health to save the credit card indicated below on file.
I authorize Heading Health to process the above credit card as "card on file". I understand this authorization will remain in effect until the expiration of the credit card account. Patient may also revoke this form by submitting a written request to the medical practice.
Cardholder's Signature

Clear
Date of Signature

MonthDayYear
Date
Name as it appears on the credit card:

First NameLast Name
Type of Credit Card

VisaMasterCardDiscoverAmerican Express
Credit Card Number:
Expiration Date:
Security Code:
This number can be found on the back of your card and should be 3 to 4 digits long in most cases
Should be Empty:

Demographics Questionnaire

Emergency Contact

Financial Information

Credit Card Authorization