The World Of Wellness (WOW) Center

Web: www.theWOWcenter.net
60 Evergreen Place - Suite 903
East Orange, New Jersey 07018
Phone: 973-676-5800
Fax: 973-676-5801

Please print name as it appears on the insurance card.

Please print then fill out this form and fax it to the Intake Coordinator at (973) 676-5801

Patients first name ____________________________________________________Last name_____________________________________________

Home Address_________________________________City__________________________State___________ Zip _____________

Home phone ____________________ Work phone_____________________ Okay to call? ❑ Yes ❑ No      Cell phone ___________________

Patients date of birth________________ Age __________ Patients SS #____________________ Sex________

Name of insurance co.___________________________________________________ Mental health Co. ___________________________________________________________

Phone number of Mental Health Co. _______________________________________  Policy ID # (if different from social_____________________________________________________________________________________________________________

Policy holders name _____________________________ Policy holders Employer ___________________________________________________________________________

Employee Assistance Program (EAP) ❑ Yes ❑ No If yes, employer name __________________________________________________________________________________

Please check the service requested: ❑ Medication management ❑ Therapy (family/individual/couple/group) ❑ Both

Patient referred by ____________________________________________________________________

What is prompting the patient to seek treatment? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________

Best time to call______________________________________________ Leave message? ❑ Yes ❑ No

Has the patient had prior inpatient or outpatient treatment? ❑ Yes ❑ No If yes, where ____________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________

Please list patients conditions/allergies to medications __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________

Patients current mental health medications ____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________

Please list any other special needs or requests _________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________

The following is for internal use only:

Assigned to _______________________ Date/Time________________________

• Please allow 48 hours for Intake Coordinator to contact you.