Client Referral Form

Client Referral Form

Please fill out the following information as completely as possible.
Name*

First NamePatient's Last Name
Date of Birth*

MonthDayYear
Date
Gender*
Ethnicity
Parent/Guardian (if patient a minor)
Marital Status*
Spouse/Partner Name
Address*

Address Street

Street Address Line 2

City/State/Zip CodeState / Province

Postal / Zip Code
Home Phone*
Can I leave a message:*

YesNo
Mobile Phone*
Can I leave a message*

YesNo
Can I send a text message?*

YesNo
Work or Other Phone
Can I leave a message

YesNo
Email Address*
example@example.com
Can I send emails?*

YesNo
Preferred Method of Contact*

HomeMobileTextEmail
Emergency Contact*

First Name Last Name
Relationship to Client*
Contact Number*
Referral Source*
Primary Care Physician*
Physician Phone*
Physician Address*
Can I contact your Primary Care Physician?*

YesNo
Major Illnesses*
Allergies*
Previous Psychiatric Hospitalization?*

YesNo
If Yes, Agency, Location, and time period
Previous Mental Health Services?*

YesNo
If Yes, Agency, Location, and time period
Driver's License Number*
Employer*
Employer's Address
By signing this I acknowledge that I can be contacted via the ways listed above. I further agree to contact Anew Life Counseling and Consulting Group, LLC, if any of the above information changes.
Signature*

Clear
Date*

MonthDayYear
Date
Assignment of Insurance Benefits and Billing Authorization
Client Name*

First NameLast Name
Policy Holders Date of Birth*

MonthDayYear
Date
Insurance Policy Holder Name*
Relation To Client*

SelfSpouseParent
Primary Insurance*
Secondary Insurance
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Primary Insurance Policy #*
Secondary Insurance Policy #*
Group Number
Please upload a copy of your insurance card *

Cancelof
Assignment of Benefits
I hereby assign all medical and mental health benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other mental health/medical plan, to issue payment check(s) directly to Anew Life Counseling and Consulting Group, LLC for therapy services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
For Office Staff Only
Check Office Location

TallahassseeQuincyOther
Fee Case Type (DCF, EAP, P&P, etc.)
www.anewlifeccgroup.com 850.508.4624 Office 850.512.1301 Fax
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Client Referral Form

Assignment of Insurance Benefits and Billing Authorization

For Office Staff Only