Start the Process - Lutheran Services in Iowa

Call Central Intake at 888-457-4692 with questions

Client Information

First Name

Middle Name

Last Name

Date of birth

MM/DD/YYYY

Gender or Gender Identity

Male

Female

Personal Pronouns

Age

School (if applicable)

Reason for Services

Race

Black (African American)

Asian

Caucasian

Native American

Pacific Islander

Not Provided

Ethnicity

Asian (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Hispanic or Latino

Native American or Alaska Native (Not Hispanic)

Two or More Races

Two or More Races (Not Hispanic or Latino)

White (Not Hispanic or Latino)

Not Provided

Preferred Language(s)

Religion

Program Type

Mental Health Therapy Services (re)Assessment Only BHIS - Behavioral Health Intervention (Only covered by IA Medicaid) Refugee and Immigrant Mental Health

Parent Guardian Information

Parent/Guardian Name

Relationship to Client

Marital Status

Primary Custody

If biological parents are not married or child is in foster care/placement *bring custody agreement/court order stating who has leagal guardianship to 1st meeting.*

Current Address

City

State

Zip

County of Settlement

How does client or parent/guardian prefer to be contacted?

Phone

Text

Would client or parent/guardian like appointment reminders?

Yes

Unknown

Referral Information

Who referred you to Lutheran Services of Iowa? OR Please give your information if you are the referral source.

Referral Date

Referral Name

Referral Phone

Organization

State

Payment/Insurance Information

Medicaid #

MCO Provider

Wellpoint

Iowa Total Care

Molina

Insurance ID #

Active

Yes No

Other Insurance Provider (if applicable)

Other Insurance Policy Holder

Policy Holder Address

Insurance ID#

Other Insurance Phone

Relationship to client

Policy Holder Phone

Group #

Other Insurance Claim Address

Employer

Policy Holder Date of Birth

Private Pay Guarantor