Confidential Intake Form

CONFIDENTIAL INTAKE FORM
PERSONAL INFORMATION
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
SSN
E-mail
example@example.com
Address

Street Address / Unit #

Apt/Unit #

CityState

Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Ext.
Preferred Contact Method (for rescheduling purposes)
Primary Care Physician
Full Name of PCP (enter "none" if applicable)
PCP Office Phone
Format: (000) 000-0000.
Ext.
Emergency Contact
Full Name of an Emergency Contact
Phone
Best number to reach Emergency ContactFormat: (000) 000-0000.
Relationship to Applicant
RESPONSIBLE PARTY
- Name
  
  First NameMiddle InitialLast Name
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Gender
- Address
  
  Street Address / Unit #
  
  Apt/Unit #
  
  CityState
  
  Zip Code
- E-mail
  example@example.com
- Home Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Work Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship to Patient
- Secondary Responsible Party

INSURANCE INFORMATION
Name of Primary Insurance Company
Address

Street Address

Bldg. / Suite #

CityState

Zip
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name of Insured
(only if different from client)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance ID #
Group #
Name of Secondary Insurance Company (if applicable)
Address

Street Address

Bldg / Suite #

CityState

Zip
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name of Insured
(only if different from client)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance ID #
Group #

INSURANCE COVERAGE INFORMATION
Amount of Annual Deductible
Insurance Coverage per Session:

Other:
Total Coverage per Calendar Year
or Number of Sessions
Co-payment Amount per Session
Other

AUTHORIZATION INFORMATION
Authorization Number
Number of Sessions Authorized
Authorization Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization Contact Phone
Format: (000) 000-0000.
Ext.
Authorization Contact Fax
Format: (000) 000-0000.

AUTHORIZATIONS
AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize the use of disclosure of my individually identifiable health insurance information necessary to process insurance claims. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
Signature
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS FOR INSURANCE

I authorize payment of medical benefits to my provider for services performed.
Signature
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FINANCIAL POLICY

Appointment cancelled with less than 24 hour notice will be charged to me at the full fee per hour. I am responsible for the entire balance of services performed regardless of whether there is insurance coverage. Secondary insurance will be billed as a courtesy.

I understand and agree to the above stated financial policy.
Signature
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: