Intake Form

Basic Agency Information

Agency Name (legal name)

Doing Business As (DBA)

Address

Phone

Email

Alternate Email

Fax

NPI#

EIN (TAX) ID#

Owner 1/ Administrator information

Name

Ownership %

Date of Birth

Social Security #

Texas Driver License Expiration

Professional License Expiration

TX Driver's License #

Professional License #

Aliases (any other names used) Relationships / ownership or management role with other agencies?

Resume Available?

Presurvey CBT modules done/attached

Citizen?

If no, include Green Card Identification #

Alternate Administrator Details

Alt Admin Name

Alt Admin Aliases

Alt Admin DOB

Alt Admin SS#

TXDL Expiry

Professional License Expiry

TX Driver's License #

Professional License #

Citizen?

If no, include Green Card Identification #

Resume Available?

Presurvey CBT modules done/attached

Relationships / ownership or management role with other agencies?

Alternate Administrator is an owner too

Owner 2 (If Applicable)

Name

Ownership %

Date of Birth

Social Security #

Texas Driver License Expiration

Professional License Expiration

TX Driver's License #

Professional License #

Aliases (any other names used)

Relationships with other agencies?

Citizen?

If no, include Green Card Identification #

Owner 3 (If Applicable)

Name

Ownership %

Date of Birth

Social Security #

Texas Driver License Expiration

Professional License Expiration

TX Driver's License #

Professional License #

Aliases (any other names used)

Relationships with other agencies?

Citizen?

If no, include Green Card Identification #

About Your Agency

To help us create your marketing materials, website, and social media pages, please share some information about your agency.

Logo (upload a .png or .jpeg file)

Slogan (optional):

Business Hours

Day	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

On call on Saturday?

Yes

No

On call on Sundays?

Yes

No

What areas does your business service?

Mission/Vision Statement (optional)

Online Presence

Show agency's address on website?

You can omit the address if it's your home.

Yes

No

Have a Facebook page?

To create a Facebook page, you'll first need a personal Facebook account.

Yes

No

Existing Facebook Page Link (if applicable)

Existing Instagram Page Link (if applicable)

Client Payment Information

What payment methods do you accept from clients?

Does your agency accept insurance?

Yes

No

Agency Intake Form

Basic Agency Information

Owner 1/ Administrator information

Alternate Administrator Details

Owner 2 (If Applicable)

Owner 3 (If Applicable)

About Your Agency

Online Presence

Client Payment Information

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