CLIENT INTAKE FORM

CLIENT INTAKE FORM

Please complete all required fields and upload your insurance card (front and back). Your information is kept private and secure.
Client Status
I am already a Total Control clientI am new to Total Control
Parent/Guardian Information
Parent/Guardian Name*

First NameMiddle NameLast Name
Parent/Guardian Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Child/Children Information

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Insurance Provider*
Insurance Card Upload (Front)*

Cancelof
Insurance Card Upload (Back)*

Cancelof
Member ID / Policy Number*
Group Number
Policy Holder Name *

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Consents & Authorizations
By signing, I consent to my child(ren) receiving counseling services with Total Control Counseling and acknowledge HIPAA privacy practices. I authorize the release of necessary information for treatment and billing, allow Total Control Counseling to bill my insurance, and give permission to verify eligibility and benefits. I understand I am responsible for copays, deductibles, or balances not covered.
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent/Guardian Signature

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Date*

MonthDayYear
Date
Should be Empty:

Client Status