Therapy Registration Form

  • The Luminous Mind

    THERAPY REGISTRATION FORM
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  • Client's Demographic Information

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client. Also, please be aware that it is the responsibility of the parents/guardians of a minor to inform The Luminous Mind if there are any stipulations relating to the legal custody or care of a minor.
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  • Contact Information

  • Emergency Contact Information

  • Familial/Relational Information

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.

  • Developmental Information

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.

  • Health Information & History

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.
  • Rows

  • Insurance Information & Authorization form

  • I understand and agree to the following:

    • I authorize the release of information from my medical record to the insurance company or other third-party payer(s) named above. This information shall include only the information necessary to submit and process claims, such as my name, date of birth, address, medical diagnosis, and services provided to me.

    • I understand that insurance billing requires a completed and signed Insurance Authorization Form. Failure to complete and sign this form will result in services being treated as self-pay and will render me financially responsible for all charges incurred.

    • This authorization shall be effective for the duration of my treatment with The Luminous Mind unless I contact the practice in writing to revoke it. If this occurs while receiving treatment, I understand that I will be asked to make other financial arrangements to cover charges.

    • I understand that I am responsible for accurately disclosing the presence of any and all insurance coverage, and that by failing to do so I accept financial responsibility if other insurance coverage is discovered at any point in the future.

    • If no insurance company is indicated, I attest to the accuracy of this information and that I will not be requesting any back billing.

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