General Information Form

Hicks Counseling Services
Beverly Hicks, M.Ed.
NC: LCMHC, CCS, CADC
TX: LMFT, LCDC2301

Mailing: 9650 Strickland Rd. Suite 103-424
Raleigh, NC 27615

Office: 919.904.4257
Fax: 866.594.1848
www.hickscounseling.com

Hicks Counseling Services, PLLC.

Beverly Hicks, M.Ed.NC: LCMHC, CCS, CADCTX: LMFT, LCDC
GENERAL INFORMATION FORM
Last Name: *
First: *
Middle Initial:
Nickname:
Sex: *

Male Female
Date of Birth *

Month Day Year
Date
Home #:

Area Code Phone Number
Mobile Number: *

Area Code Phone Number
Email: *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Marital Status *

Married Single Separated Divorced Widowed
Are you 18 years of age? *

Yes No
Mother's Name:
Mother's Phone Number

Area Code Phone Number
Father's Name:
Father's Phone Number

Area Code Phone Number
Name of Responsible Party Covering Deductibles and Co pays: *
Same as address above?

Yes No
If not, Street:
City:
Zip:
Primary Care
Primary Care Physician's Name: *
Phone: *
Current Medications
Primary Insurance Coverage
Insurance Co: *
Primary Telephone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy #: *
Group #: *
**Please present your card to therapist to be photocopied or upload a picture here.
Upload your insurance card (Front)

Browse Files

Cancel of
Upload your insurance card (Back)

Browse Files

Cancel of
Mental Heath Insurance Coverage If Applicable
Do you have mental health coverage?

Yes No
Insurance Co.:
Phone Number

Area Code Phone Number
Claims Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy #:
Group #:
Is Pre-Authorization Required?

Yes No
If Yes, Authorization #:
Authorized # of Visits:
Start Date:

Month Day Year
Date
End Date:

Month Day Year
Date
Assignment and Release
I, the undersigned certify that I (or my dependent) have insurance coverage stated above and assign payment directly to entity named above all insurance benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor/therapist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance. I am entitled to a copy of this agreement by requesting one.
Responsible Party Signature

Clear
Relationship *
Date

Month Day Year
Date
Should be Empty:

Hicks Counseling Services, PLLC.

GENERAL INFORMATION FORM

Primary Care

Primary Insurance Coverage

Mental Heath Insurance Coverage If Applicable

Assignment and Release