Administrative Intake Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SSN#
DL#
Age/Date of Birth
Home Phone
-
Area Code
Phone Number
Mobile Phone
-
Area Code
Phone Number
Ok to leave messages?
Home Phone
Mobile Phone
Email
example@example.com
Employment Information
Employment Status
Full-Time
Part-Time
Student
Unemployed
Occupation
Employer Name
Years Employed
Billing Information
Payment Method
Self-Pay
Insured/Office File
Insured/Self File
Responsible Party
First Name
Last Name
Relationship to Patient
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Phone
-
Area Code
Phone Number
Insurance Information
Insurance Company
Subscriber SSN
Subscriber DOB
-
Month
-
Day
Year
Date
Subscriber Name
First Name
Last Name
Subscriber Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber ID#
Group#
Relationship to Patient
Employer
Emergency Contact
Full Name
First Name
Last Name
Relationship to Patient
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Patient's Primary Care Physician
Patient's Primary Care Physician Phone Number
-
Area Code
Phone Number
By signing below, I accept FULL responsibility for ALL charges for services provided by Dr.Shaw. Including but not limited to: individual, group, marital therapy, phone calls, professional consults, documentation, patient home visits, legal service, or crisis intervention. I agree to the conditions noted above and accept financial responsibility for any costs incurred for services. Insurance Authorization: I hereby authorize Dr. Robin Shaw to furnish information to my insurance carrier(s) concerning my treatment and/or the treatment of my dependents. I have read all of the information noted above and agree to all of these conditions.
*
Date of Signature
-
Month
-
Day
Year
Date
Submit
Should be Empty: