New Client Data Form

 Welcome!  In order to better serve you, we request that you provide the following information:

Name: ______________________________________________________________________________________________________

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Address: ___________________________________________________________________________________________________

                       Number                          Street                                                                     City                                         State                     Zip code

Email:_______________________________________________________________________________________________________ 

Phone Numbers: _(___)_________________________  (___)__________________________(___)____________________________

                                                Home                                                     Work                                                      Cell

Preferred method of communication, including leaving a message (please circle): home phone,  work,  cell,  email

Social Security Number: ______________________ Birth date: ___________________Age___________ Marital Status: ______

Employer: ________________________________________   Occupation: _______________________________________________

I agree to pay my session fee or copay of ________ at the end of every session.  

 How did you hear about our practice? _________________________________________________________________________

May we include you in our electronic newsletter list? YES __  NO __  (All addresses are kept private)

                                                                                          Insurance Information                                                              

Insurance Co. Name: _____________________________ Address: ___________________________________________________

Member ID# ________________________________________________Group #/Name: __________________________________

Policyholder’s Name (if different than above): __________________________________________________________________

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Address  & phone number (if different than above): _____________________________________________________________

____________________________________________________________________________________________________________

Insured’s Employer Name: ________________________________ Insured’s  Birthdate: ________________________________

Insured’s Relationship to Client: _______________________________________  Plan year starts: _______________________

 Ins. Co Phone # to verify coverage: _____________________  Are authorizations required for treatment? YES ___ NO ___

Annual deductible for behavioral health: _____________________________________________________________________

Limits of coverage: ________________________________            Do you have a secondary insurance policy:      YES __  NO __

For office use only: