New Client Intake Form

NEW CLIENT INTAKE FORM

PATIENT INFORMATION:

Patient Name: (Last, First) ______

Patient Address: (Street/PO Box) ______

(City, State & Zip) ______

Patient Telephone No: (Best Contact) ______

Patient Date of Birth ______

Patientemail ______

RESPONSIBLE PARTY INFORMATION: (The person who signs this agreement will be the responsible party. For a minor, you must be the parent, adoptive parent, or legal guardian).

Resp. Party Name: (Last, First) ______

Resp. Party Address: (Street/PO Box) ______

(City, State & Zip) ______

Resp. Party Telephone No: (Best Contact) ______

Resp. Party Date of Birth ______

Relationship to patient: ______

PRIMARY INSURANCE SUBSCRIBER INFORMATION:

Name: (Last, First) ______

Address: (Street/PO Box) (Write same as above if same) ______

(City, State & Zip) ______

Telephone No: (Best Contact) ______Date of Birth ______

Name of Insurance: ______Ins. 1-880 phone no. ______

Member ID No: ______Relationship to patient: ______

PROVIER/CLIENT SERVICE AGREEMENT

(Initial to the left of each section to indicate your agreement)

______I have reviewed my provider’s informed consent material and the policy on (Initial) insurance and billing practices and understand the provisions in it.

______I authorize my provider to use and disclose the necessary health and (Initial) clinical information for me or ______for the purposed of payment and health care operations. I authorize payment of medical benefits to my mental health provider for services rendered.

______I am willing to have contact via my email address and/or text message

regarding appointment reminders or billing questions.

______I understand that there is a 24 to 48 hourcancellation policy. If that notice is not given, than I am responsible for the cost of the session.

______I understand it is my responsibility to provide current, correct insurance

information now and to inform me within 30 days of any insurance coverage change. I do understand that my provider bills my insurance company as a courtesy to me and that any denied claim becomes my responsibility. Finally, I understand that my provider reserves the right to charge me for administrative costs to rebill claims if I have not provided current, correct insurance information.

______If applicable, as parent or legal guardian of ______,

I have read the Contract for Therapy with Minor form. I consent to evaluation and treatment of my minor child and agree to be responsible for any costs incurred.

I understand the above and agree to the provisions for those sections I have initialed above.

Please Print Name: ______

Signature: ______Date: ______