CCCSGD INTAKE FORM

CLIENT INTAKE
Date

MonthDayYear
Date
Staff
CLIENT INFORMATION
Clients Last Name
First
Middle
If not what is your legal name
Former Name
Age
Address

Street Address

Street Address Line 2

CityState

ZIP Code
PO Box
City
State
ZIP Code
Occupation
Employer
Referred to Provider by (Please check one box & list) Family
Email Address
example@example.com
Alternative Email Address
example@example.com
Phone Number
Please enter a valid phone number.
INSURANCE INFORMATION
(PLEASE GIVE YOUR INSURANCE CARD TO THE OFFICE MANAGER)
Person Responsible for Bill
Email Address
example@example.com
Address if different
Occupation
Employer
Employer Address
Is this client covered by insurance?

Yes NoTotal Annual EAPs allowed?
Total Annual EAPs allowed
Please Select Your Primary Insurance Provider

Beech StreetBlue Cross/Blue SheildChoiceCareChampus Amerigroup First HealthHealthSmartHumanaMagellan/AetnaMedicaid Cigna Definity Health PHCSPMHSTexas One ChoiceTriCare MedicareMHN/MHNetUnicare United HealthcareOther Value Options
What is the authorization number
Insureds Name
Insureds SS
Group
Policy
Client's Relationship to Insured
Name of Secondary Insurance if any
Insureds Name
Group
Policy
Other
IN CASE OF EMERGENCY
Name of Local Friend or Relative (not living at same address)
Relationship to Client
Phone Number
Please enter a valid phone number.
REQUESTED FUNDS
CSGD COUNSELING CLIENT INTAKE FORM
PLEASE READ THE FOLLOWING CAREFULLY
I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. I will honor contractual agreements made with those managed health care companies which stipulate specific reimbursement restrictions.
CLIENTGUARDIAN SIGNATURE

Clear
DATE

MonthDayYear
Date
I hereby consent to treatment by specified provider. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have a right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.
CLIENTGUARDIAN SIGNATURE

Clear
DATE

MonthDayYear
Date
I hereby authorize the release of necessary medical information for insurance reimbursement
CLIENTGUARDIAN SIGNATURE

Clear
DATE

MonthDayYear
Date
CLIENTGUARDIAN SIGNATURE

Clear
I authorize the payment of medical benefits to the provider of services.
DATE

MonthDayYear
Date
CLIENTGUARDIAN SIGNATURE

Clear
Should be Empty:

CLIENT INTAKE

CLIENT INFORMATION

INSURANCE INFORMATION

(PLEASE GIVE YOUR INSURANCE CARD TO THE OFFICE MANAGER)

IN CASE OF EMERGENCY

CSGD COUNSELING CLIENT INTAKE FORM

PLEASE READ THE FOLLOWING CAREFULLY