New Client Intake Form

New Client Information
Associates In Psychotherapy
Deerfield • Evanston • Chicago • Barrington
(866) 220-8371
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile/Work Phone
Please enter a valid phone number.
Which phone number is the best one to reach you?

Home PhoneMobile/Work Phone
Any restrictions on phone calls or messages?

YesNo
Do you want to receive Appointment Reminders?

YesNo
If yes, by Email or Text?

EmailText
Email Address
example@example.com
How did you hear about our practice?
Date of Birth

MonthDayYear
Date
Age
Marital Status
Gender
Parent/Guardian Information
Parent/Guardian Last Name:

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Front of insurance card

Cancelof
Back of insurance card:

Cancelof
Name of Insurance
Relationship to Client
Date of Birth of Policyholder

MonthDayYear
Date
Social Security Number of Insured
Policy Number
Group Number
Address of Policyholder

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile/Work Phone
Please enter a valid phone number.
In Case of Emergency
Emergency Contact

First NameLast Name
Relationship to Client
Home Phone
Please enter a valid phone number.
Mobile/Work Phone
Please enter a valid phone number.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Associates In Psychotherapy. I understand that I am financially responsible for any balance. I also authorize Associates In Psychotherapy or the insurance company to release any information required to process my claims.
Name*

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear
Date
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Client Information

Parent/Guardian Information

Insurance Information

In Case of Emergency