New Client Information

New Client Information

Emilie Moreau, MA, Rostered Psychotherapist
Name*

First Name Last Name
Date of Birth*

MonthDay Year
Preferred Pronouns
What sex were you assigned at birth?

FemaleMale
Social Security Number*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
May I leave a message for you at this number?*

YesNo
Occupation

UnemployedEmployed Part-TimeEmployed Full-TimeStudent
Relationship Status

SingleMarriedDivorcedCivil UnionSeparatedWidowedDomestic partnership, living togetherPartnered, not living togetherPrefer not to respondOther
Emergency Contact *
Full Name
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Invoices-Choose One*

I agree to have invoices sent to me through emailI would prefer statements be sent through a different agreed upon method
*No diagnostic information will be included on statements, but I understand that e-mail is not a secure form of communication and the statements sent will include information such as my name, address, and type of services I have received
Primary Insurance Information*
Insurance Company Name
ID Number (only needed if you have BCBS)
Group Number (only needed if you have BCBS)
Name and relationship to primary insured*
How would you rate your health?

ExcellentGoodFairPoor
Do you have any chronic illness, pain, injury or other physical problems?

YesNo
If yes, please explain
Are you currently taking any medication?*

YesNo
If yes, please list them with the condition they are used to treat and any side effects you experience:
Primary Care Physician
Name
Primary Care Company Name
Phone Number
Can we contact?

YesNo
Have you sought therapy before?*

YesNo
If yes, when (year) and where (state)
Please list any previous hospitalizations or treatment for mental health outside of therapy if applicable
Please describe your current reason for seeking therapy:*
Please list any additional information you feel like I should know below
I authorize the release of any medical or other information necessary to process my insurance claim. I have received disclosure information from Emilie Moreau regarding her training and policies regarding fees and payment, confidentiality, cancellations and emergencies and I agree to abide by these policies and procedures. I understand that if my health insurane company does not cover the servcies I receive from Emilie Moreau, I will be responsible for paying the associated fees in full. I understand it is my responsibility to determine whether or not my health insurance will cover outpatient mental health services with Emilie Moreau. I have also received information concerning unprofessional conduct for allied mental health professionals according to Vermont statutes and a Notice of Privacy Practices regarding the Health Insurance Portability and Accountability Act (HIPAA).
Name of Adult Client or Legal Guardian*

First Name Last Name
Signature of Adult Client or Legal Guardian*

Clear
Name of Youth

First Name Last Name
Signature of Youth

Clear
Date*

MonthDay Year
Date
Should be Empty: