Client Pre-Intake Form
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Are you a UK Employee?
Please select...
Yes
No
Client First Name
Client Last Name
UK Employee Linkblue (i.e. jsmith123)
Client Date of Birth
Client Last 4 Digits of Social Security Number
Licensure Disclosure
Due to board licensure requirements, all mental health telehealth appointments must occur in the state of Kentucky. If you live and/or work from a location outside Kentucky, please schedule an appointment with LiveHealth Online at
www.livehealthonline.com
,which is currently offering $0 co-pays for behavioral health services.
I have read the above and will be physically located in KY for the time of my appointment?
Yes
No
Due to board licensure requirements, all telehealth appointments must occur in the state of Kentucky. If you live and/or work from a location outside Kentucky, please schedule an appointment with LiveHealth Online at
www.livehealthonline.com
.