CLIENT INFORMATION FOR JEFFREY R. PETRA, PH.D.:

Please provide information/circle responses as appropriate. Please give legal name (s) with middle name. Please note other names in parentheses.

Client Name: ______Gender: M F Birthdate:______

Address: ______H. Phone ( ) ______

______W. Phone( ) ______

Employer/School:______C. Phone ( )______

E-mail Address: ______School Phone ( ) ______SSN:______

Spouse/Partner: ______

Parent 1: ______Gender: M F Birthdate:______

Parent 2: ______Gender: M F Birthdate:______

Address: ______H. Phone ( ) ______

______W. Phone ( )______EE

E-mail Address: ______C. Phone ( )______

Employer/School:______SSN : ______

Stepparent: ______

Spouse/Partner: ______Gender: M F DOB:______

Please Specify the Custodial Parent(s):______

Please Specify thePerson Responsible for the Bill:

Name: ______Gender: M F Birthdate:______

Address: ______H. Phone: (______)______

______W. Phone: (______)______

Employer/School:______SSN:______Married: Y N

Relationshipto Client:______

In Emergency Notify Relative: ______Phone: (______)______

In Emergency Notify Friend: ______Phone: (______)______

Referred by:______

Primary Insurance Co.: ______

(Note: Please be sure to include any alphabetical designator, such as "ZLA," which predecessor

is included as part of your Group or ID Number. Some companies will not reimburse without it.

Group #: ______ID #: ______Ins. Phone: (_____)______

Name of Insured:______Relationship to Client: ______

Insurance Billing Address: ______

Insured's Employer:______

Secondary Insurance Co.: ______

Group #: ______ID #: ______Ins. Phone: (_____)______

Name of Insured:______Relationship to Client: ______

Insurance Billing Address: ______

Insured's Employer:______

The above information is accurate to the best of my knowledge. I have read, understood, and agreed to the Statement of Office Policy, Privacy Practices, Consent to Treatment & Limits of Provider Liability. I authorize my insurance benefits to be paid directly to the provider, acknowledge that I am responsible for any balance due, and I authorize the provider to release any information required to process manual and electronic insurance claims. I have read, understood, and agreed to the Documentation of Understanding Regarding DSHS Insurance Coverage. I will not withhold or delay payment because of any insurance/third party involvement.

Signature of Client: ______Date: ______

Signature of Person Responsible for Bill:______Date: ______