Intake Form

Grace Riddell, LICSW, LCSW-C and Associates

griddell4@gmail.com | (202) 669-4379 | www.grace-riddell.com
Patient Information
Patient Name*

First NameLast Name
Gender*
Social Security Number
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Would you like to receive occasional emails with items of interest, including upcoming therapy groups or events?*

YesNo
Occupation
Employer
Employer Phone Number
Format: (000) 000-0000.
Primary Care Physician

First NameLast Name
Primary Care Physician Phone Number
Format: (000) 000-0000.
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Person Responsible for Bill*

First NameLast Name
Is this patient covered by insurance?*

YesNo
Home Phone Number*
Format: (000) 000-0000.
Insurance Company
Group Number
Located on your insurance card
Policy Number
Located on your insurance card
Insurance Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Claims Phone Number
Format: (000) 000-0000.
Please upload a copy of your insurance card (front and back)

Cancelof
In Case of Emergency
Emergency Contact*

First NameLast Name
Relationship to Patient*
Phone Number*
Format: (000) 000-0000.
Payment is expected at the time of service. I am responsible to provide a referral and/or authorization if required by my insurance company. I am responsible for
remembering all scheduled appointments. All appointments must be cancelled at least 48 hours in advance by voicemail only. Emails are not acceptable for
cancellations or changes in appointments. Missed appointments and late cancellations are charged as FULL FEE. Account balances must be paid
within 30 days. Account discrepancies must be settled within 60 days. We are not responsible if your insurance does not pay or if they pay incorrectly. There will
be a charge of $30 for any returned checks. Interest will be charged at the rate of 1.5% per month (18% annually) for any balance more than 30 days old. I
acknowledge that I am fully responsible for payment of the total bill incurred and I will be responsible for paying costs of collection action and reasonable
attorney’s fees. I am responsible for payment for the amount not covered if my secondary insurance to my Medicare insurance does not pay the full amount.

AUTHORIZATION: By signing below this is authorization for Grace Riddell, LICSW, LCSW-C to apply for benefits on my behalf under Medicare or any private
insurance company listed on this form. I further authorize the release of any necessary medical information for any claim to my insurance company, primary
care physician or managed care network.
Signature of responsible party*
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Grace Riddell, LICSW, LCSW-C and Associates

Patient Information

Insurance Information

In Case of Emergency