Full Name:
*
Preferred Name:
Gender:
*
Date of Birth:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Billing Address:
*
City
*
State:
*
Zipcode:
*
Cell:
*
Contact Information (for guardian of minor children):
Please let us know the name/phone number of the guardian 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 Number:
*
Primary Insurance Holder Name:
*
Primary Insurance Holder Date of Birth:
*
Primary's Relation to Patient:
*
Type Self if the primary is the patient.
Employer (if policy through job):
Secondary Insurance company:
Leave Blank if you do not have secondary insurance coverage
Secondary Insurance Contract Number:
Secondary Insurance Holder Name:
Secondary Insurance Holder's Date of Birth:
Referred by:
Requested Therapist:
Please describe in detail why you are seeking services:
*
This information will be released to your therapist.
Are you currently or will you be involved in legal proceedings?
*
Yes
No
Other
Submit
Should be Empty: