Intake Form

Intake Form

Laurel D. Fraser MA LMFT
Date of Intake*

MonthDayYear
Date
Hour MinutesAM/PM Option
Name*

First NameLast Name
Age*
Date of Birth
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Reason for seeking therapy at this time
Emergency contact: Name*
Emergency contact: Relationship*
Emergency contact: Phone*
YesNo
SingleMarriedLiving with PartnerSeperatedDivorcedWidowed
Spouse/Partner Name
Friend/RelativePhysician or TherapistInsurance CompanyPsychology TodayGoogle/Online SearchOther
Insurance Company
Insurance Company*
Insurance ID Number*
Insurance Participant Name*
Insurance Participant's DOB*
Insurance Participant's SSN
Insurance Participant's Employer (for insurance form purpose)*
Note: co-pays may be adjusted up or downafter the first claim is made and the insurance company determines the exact amountof co-pay for your particular plan.

We require all clients to fill out a credit card authorization sheet. We will keep this information and your signature on record and your card will be charged if session fee, co-pay or deductible is not paid at the time of the sesion. You may also inform us if you would like your co-pays sesion fees automatically charged on a weekly or monthly basis, in lieu of ccheck or cash payment.
Previous Counseling: When
Previous Counseling: How Long
YesNoOther
YesNoOther
YesNo
Dr's Name
Location/Phone
Dr's Name
Location/Phone
Describe care - Please list any prescription medications you are currently taking, and for what purpose they were prescribed. Please note any side effects you are experiencing
NeverSeldomFrequentlyDailyUsed in the Past
NeverSeldomFrequentlyDailyUsed in the Past
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature*

Clear
Should be Empty:

Intake Form

Insurance Company