New Client Referral Form

New Client Referral Form
Date

MonthDayYear
Date
Client Name

First NameLast Name
Legal Name (If Different)

First NameLast Name
Date of Birth (MM/DD/YYYY)
Gender Identity
Pronouns
Sex Assigned at Birth (needed for Insurance/Billing purposes only):
Home/Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is it okay to leave a voicemail?
Email
example@example.com
Primary Insurance Company Name & Member ID# (including alpha prefix):
Primary Insurance Company Group Number:
Name of subscriber of the above policy, if different from client:
(If Applicable) Secondary Insurance (Such as Medicare) Company Name & Member ID# (including alpha prefix):
(If Applicable) Secondary Insurance Company Group Number:
Name of subscriber of the above policy, if different from client:
(If Applicable) Additional/Tertiary Insurance (Such as Medicare) Company Name & Member ID# (including alpha prefix):
(If Applicable) Additional/Tertiary Insurance Company Group Number:
Name of subscriber of the above policy, if different from client:
Emergency Contact Information

Please provide the name & contact information for whom we should contact in the case of an emergency:
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Client:
If Client is a Minor

Please complete the following section if the client is a minor:
Guardian Name

First NameLast Name
Relation to Client
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email
example@example.com
Have you ever been a client at Art of Awareness?
If you responded "Yes" to the question above, please provide your past therapist's name:
Do you have a partner, friend, or family member who is working with an Art of Awareness therapist, and/or do you personally know or are related to an Art of Awareness staff member?
If you responded "Yes" to the question above, please provide the therapist's name:
Do you have a preference for sessions to be conducted in-person, by telehealth, or are you open to either?
Do you have a preference for weekly or biweekly sessions?
Which type(s) of therapy are you seeking?
Which days and times are you available for sessions?
Please tell us more about which topics you would like to discuss in therapy:
Do you overuse or abuse any substances/alcohol/drugs?
Do you have disordered eating?
How did you hear about Art of Awareness?

Other
If you were referred by another provider, please provide their Name & Practice Name
Should be Empty:

New Client Referral Form

Emergency Contact Information

If Client is a Minor