Client Update Form

Client Update Form

Anchored in Hope Counseling Services LLC. 33 Beaver Drive, Suite L Dubois, PA 15801 (814) 299-7771
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Yes (if yes, please complete changes in sections below)No (if no, continue to release section)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Number
Format: (000) 000-0000.
YesNo
Secondary Number
Format: (000) 000-0000.
YesNo
Email
example@example.com
Emergency Contact*

First NameLast Name
Phone Number
Format: (000) 000-0000.
By listing this person, I authorize the release of necessary information listed person in the event of an emergency or the inability to contact me for scheduling or treatment purposes.
If Minor, Parent/Guardian

First NameLast Name
Phone Number
Format: (000) 000-0000.
Insurance/Payment Information
Insurance Company
Policy Number
Group Number
Subscriber Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Secondary Insurance Company
Policy Number
By offering this information, I agree to allow this practice to release necessary information to the above insurance company and insurance subscriber to submit billing claims on my behalf.
Release of Information

I authorize Anchored in Hope Counseling Services LLC to release or receive information including medical records, treatment plans/summary, and diagnosis to the following family/ friends for reasons such as discussing concerns, contributing to treatment goals, and any other opportunities to support treatment:
Client Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Signature*

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Client Update Form

Insurance/Payment Information

Release of Information