Integrated Life Therapeutic Solutions
Client Information
First Name
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Last Name
*
Date of Birth
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Address
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Email Address
*
Contact Number
*
Gender
*
Photo of Government identification Front and Back
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Parent/Guardian information: (If Under 18)
Name
Relationship to Client
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Mother
Father
Guardian
Other
Mobile Number
Address
Phone
Do you have Insurance?
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Cash Pay/Out of pocket
Insurance Company
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Member ID
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Group
Photo of Insurance Card: (Front and Back)
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Presenting Problem:
Reason for Seeking Treatment
Reason for Seeking Treatment/ Diagnosis (If applicable)
Please use the following for any additional pertinent information, special requests or Client expectations:
I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.
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