General Information Form

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

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:*

MaleFemale
Date of Birth*

MonthDayYear
Date
Home #:

Area CodePhone Number
Mobile Number: *

Area CodePhone Number
Email:*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*

MarriedSingleSeparatedDivorcedWidowed
Are you 18 years of age?*

YesNo
Mother's Name:
Mother's Phone Number

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

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

YesNo
If not, Street:
City:
Zip:
Primary Care
Primary Care Physician's Name:*
Phone:*
Current Medications
Primary Insurance Coverage
Insurance Co:*
Primary Telephone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / 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

Cancelof
Upload your insurance card (Back)

Browse Files

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

YesNo
Insurance Co.:
Phone Number

Area CodePhone Number
Claims Mailing Address

Street Address

Street Address Line 2

CityState / Province

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

YesNo
If Yes, Authorization #:
Authorized # of Visits:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
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

MonthDayYear
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