Your email TODAY'S DATE: IDENTIFYING INFORMATION Legal Name: Preferred Name: Date of Birth: Age: Relationship Status: Partner’s Name (if being seen as a couple): Address: City, State, Zip: Home phone: Work phone: Partner’s phone: May we leave messages for you at home? YesNo May we leave messages for you at work? YesNo Gender as Specified on Insurance:MaleFemale Gender Self-Identification, if different:MaleFemaleOther If Other: Others Living in Home (name, birth date, relationship to client): Education: Self: Partner: Occupation: Self: Partner: Client’s Employer: Emergency Contact: Phone: Referred by: INSURANCE INFORMATION ( leave blank for self pay) Name of Insured: Insured Date of Birth: Address of Insured: City, State, Zip: Relationship of Client to Insured: Employer of Insured: Insurance Company: Phone: Insurance Company Address: City, State, Zip: Insurance Identification Number: Group Number: Secondary insurance: Phone: Name of Secondary Insured: Insured Date of Birth: Secondary Company Address: City, State, Zip: Secondary Identification Number: Group Number: PATIENT OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process a claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the provider of services. Signature: Date:
