TODAY'S DATE:  ________________                                                                                                                             

Patient Name:  ______________________________________________________________________________________

                                    Last                                          MI                                 First

 Single     Married     Divorced   ∫∫    Employed    Full Time Student    Part Time Student    

Sex: M / F          Age:  _______   Birthday:  _______ / _______ / _______     SS#:  ______________________________________

_____________________________________________________________________________________________________________

Home Address: (please do not use P.O. Box numbers)  

_________________________________________________________________________________________________________________________

                                    City                                                                         State                                                                      Zip

Home Phone:  (       )  _____ - __________   Work Phone:  (       )  _______ - _________    Cell: (______) _______-________

Employer/School grade)______________________________________________________________

                     (Students)

Confirm appointment with: ________________________________________               Phone:  _____________________________

≈  INSURED'S INFORMATION  ≈        DO NOT SKIP THIS INFO. -   REQUIRED TO SUBMIT CLAIMS

 **Relationship of INSURED to PATIENT:   Self   Parent   Child   Spouse   Other

AUTHORIZATION NUMBER:  _______________________________________________   No. of Sessions Authorized:  __________

Subscriber / Insured's Name: ___________________________________________________________  DOB: __________________

Subscriber / Insured's SS#:   ________________ ____________________________________  (REQUIRED INFORMATION)

Street Address: ____________________________________________________________________________________________________________

                          If different from patient address     Please do not use P.O. Box numbers

__________________________________________________________________________________________________________________________

City                                                                          State                                                        Zip

Insured's Employer: _____________________________________________________   Insured's Phone: (     ) ______-_________

                                                                                                                                                                                     Work

Subscriber / Member ID Number: _______________________________________________________ Group Number: _____________________

                                                (This information must be complete in order to file claim)

Insurance Company Name:  ___________________________________________________________

Insurance Co.  Address:  ________________________________________________________________________________

                                           ________________________________________________________________________________

Insurance Co.  Phone No.: (          )  __________ - ________________________    How did you learn of this practice?: ____________________________

Is there second policy covering the patient?    Y    N  If "yes", Please present the insurance card to be

  copied and record the information from the card on the back of this form.

RESPONSIBLE PARTY INFORMATION

Responsible Party's Name:_________________________________________________________

 Street Address:___________________________________________________________________________

_________________________________________________________________________________________

                                                        City                                                 State                                       Zip

Relationship of Patient to responsible party:   Self   Parent   Child   Spouse   Other

INITIALS:                                                 AUTHORIZATION AND ASSIGNMENTS

_______ ITEM 1:  Consent to treatment:  I agree to accept treatment from my psychotherapist and reserve the right to refuse treatment at any time and may discuss this with my psychotherapist.

_______ ITEM 2:  RELEASE OF INFORMATION:  I hereby authorize the provider and their representatives to disclose healthcare information to my insurance company, if applicable, in order to verity benefit coverage, obtain authorization for treatment and to bill and collect for the services rendered.  I authorize my insurance carrier to make direct payments to this provider for benefits specified.

YOUR INSURANCE COMPANY WILL NOT PAY FOR MISSED SESSIONS.  Sessions that are not cancelled at least 24 hours in advance, will be billed at a standard fee of &75.00.

Patient/Parent/ Guarantor Signature ______________________________________________________    Date:   ___________________________