Full Name (first, middle initial, last):
*
Preferred Name
Gender:
*
Date of Birth:
*
/
Month
/
Day
Year
Date
Billing Address:
*
City
*
State:
*
Zipcode:
*
Cell:
*
Contact Information (for guardian of minor children):
Please let us know the best contact information if you are seeking services for a minor.
Second phone number (optional):
Email:
*
example@example.com
Insurance Company:
*
If you do not have insurance, type NA for all insurance questions.
Policy/Member/ID Number:
*
Group:
*
Primary Insurance Holder:
*
Primary Insurance Holder Date of Birth:
*
Primary's Relation to Patient:
*
Type Self if the primary is the patient.
Primary Insurance Holder Social Security Number:
*
**Can just enter last 4 digits
Employer (if policy through work):
Secondary Insurance company:
Type NA if you do not have a secondary insurance.
Secondary Insurance Contract Number:
Secondary Insurance Primary policy holder:
Secondary Insurance Primary's date of birth:
Referred by:
Please describe in detail why you are seeking therapy:
*
This information will be released to your therapist.
Submit
Should be Empty: