New Client Intake Form

Please complete this form so we can better understand your situation and how we can help. All information is kept confidential in accordance with our Privacy Policy.

Personal Information

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Street Address

City

State

ZIP

Contact Preferences

How do you prefer to be contacted? *

Best time to reach you

Medical Information

Current Diagnoses / Conditions *

Current Medications

Timeline of Health Issues

When did things start? What changed? Walk us through the progression as best you can — even rough dates help.

Healthcare Providers

Primary Care Provider

Provider Name

Provider Phone

Provider Fax

Current Specialists

List any specialists you are currently seeing — include their name, specialty, and contact info if you have it.

Insurance Information

Insurance Provider

Policy / Member ID

Group Number

Your Advocacy Needs

Please describe what you need help with *

Tell us about your situation — what's been going on, how long it's been happening, and where you feel most stuck.

What have you already tried? Where do you feel stuck?

Have you seen multiple doctors? Been denied by insurance? Tried certain treatments? Knowing what hasn't worked helps us figure out what to do next.

What are your goals for advocacy? What outcome are you hoping for?

What does "success" look like for you? A diagnosis? An approved appeal? A clearer plan? Just knowing what's going on?

One Last Thing

How did you hear about Anchor Advocacy?

I understand that Anchor Advocacy provides medical advocacy and care navigation services, not medical diagnoses, treatment, or prescriptions. I consent to having my information reviewed for the purpose of receiving advocacy services. I have read and agree to the Privacy Policy and Terms & Disclaimer. *