About
Contact
New Patient Forms

About
Contact
New Patient Forms

Student Intake

Thank you for choosing OIC Behavioral Health. Completion of this online form will help us to design the best plan of care. The form adheres to Privacy Practices and is in a safe and secure environment to protect private information.

"*" indicates required fields

Student Information

Which school does the student attend?

Williford Elementary School

Rocky Mount High School

Other

Please specify what school the student attends.*

Student Name*

First Name Middle Initial Last Name

Current Address*

Street Address Address Line 2 City State ZIP Code

Home Phone Number*

Cell Phone Number

Date of Birth*

Month

Day

Year

Sex*

Male

Female

Race*

Black

American Indian

Asian

Caucasian

Native Hawaiian

Other Pacific Islander

Decline to Specify

Other

Please specify your race if 'other' is selected.*

Ethnicity*

Hispanic/Latino

Not Hispanic/Latino

Decline to Specify

Parent/Guardian Contact Info

School information on file for all parent/guardianship/custody for this student.

Please provide contact information for parents and/or legal guardians.*

First Name

Last Name

Relationship to Student

Phone Number (555-555-5555)

Referrer

Date of Referral*

Month

Day

Year

Referral Source Name*

First Name Last Name

Referral Source Email Address

Please provide an email address where we can reach you. If you do not have one, leave blank.

Reason for Referral*

Please list any days/times that student cannot participate in therapy:

Consent*

I verify that the above information is accurate based on school records.

Comments

This field is for validation purposes and should be left unchanged.

90 Guardian Court, Rocky Mount, NC 27804 | (252) 210-9015