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.
Ok to leave a message on home phone?

YesNo
Cell Phone Number
Please enter a valid phone number.
Cell Phone Carrier
Ok to text on cell phone?

YesNo
Email Address
example@example.com
Ok to email appointment reminders?

YesNo
Sex at birth?*

MaleFemale
Gender identity?

FemaleMaleNon-BinaryTransgender-Female to MaleTransgender-Male to FemaleOther Not SpecifiedDon't Know/Not SurePrefer Not to Answer
Primary language?*

American Sign LanguageArabicBengaliBengali (Old)CantoneseCantonese/MadarinDariEnglishFarsiFrenchGujaratiHindiIlonggoKoreanManadarinMarathiPortuguesePunjabiRussianSpanishTagalogUrduUnknown/Not ProvidedOther
Preferred language for services?*

American Sign LanguageArabicBengaliBengali (Old)CantoneseCantonese/MadarinDariEnglishFarsiFrenchGujaratiHindiIlonggoKoreanManadarinMarathiPortuguesePunjabiRussianSpanishTagalogUrduUnknown/Not ProvidedOther
Race*

American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or other Pacific IslanderWhiteOther RaceUnknown/Not Provided
Ethnicity*

African-AmericanAlaska NativeAsianAsian/Pacific-IslanderBengaliCaribbean BlackCaucasianCentral AmericanChineseFilipinoHispanic/LatinoIndianKoreanMulti-EthnicitiesNative AmericanPakistaniPersianSouth AmericanSouth American (Other)Sri LankanUnknown/Not Provided
Marital Status*

DivorcedDomestic PartnerMarriedNever MarriedRemarriedSeparated (Legally)WidowedUnknown/Not Provided
Insurance Information
Associated Payer (Insurance Company)*
Insurance Policy/Plan #
Person Insurance
Client Relationship to Insured

SelfCadaver DonorChildEmployeeLife PartnerOrgan DonorSpouseOther RelationshipUnknown
Family Members/Contacts
Family Member

First NameLast Name
Family Member's Relationship to Client

SelfAdopted ChildAdoptive ParentAdoptive Parent 2AgencyAuntBiological FatherBiological MotherCaretakerChildCousinDomestic PartnerFoster ParentFriendGrandparentLegal GuardianReferral SourceSiblingSpouseOther Relation
Family Member's Phone Number
Please enter a valid phone number.
Family Member's Phone Type

HomeCell
Ok to call family member's phone?

YesNo
Consent to release personal health information?

YesNo
Is this family member the client's emergency contact?

YesNo
Clincian/Supervisor (Completed by Staff Only)
Clinician Name

First NameLast Name
Supervisor Name

First NameLast Name
Should be Empty:

BH Satellite New Client Form

Client Information

Insurance Information

Family Members/Contacts

Clincian/Supervisor (Completed by Staff Only)