BCPC BH Satellite New Client Form

BH Satellite New Client Form
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ok to leave a message on home phone?
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Carrier
Ok to text on cell phone?
Email Address
example@example.com
Ok to email appointment reminders?
Sex at birth?
Gender identity?
Primary language?
Preferred language for services?
Race
Ethnicity
Marital Status
Insurance Information
Associated Payer (Insurance Company)
Insurance Policy/Plan #
Person Insurance
Client Relationship to Insured
Family Members/Contacts
Family Member

First NameLast Name
Family Member's Relationship to Client
Family Member's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Member's Phone Type
Ok to call family member's phone?
Consent to release personal health information?
Is this family member the client's emergency contact?
Clincian/Supervisor (Completed by Staff Only)
Clinician Name

First NameLast Name
Supervisor Name

First NameLast Name
Should be Empty:

BH Satellite New Client Form