Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX Office (817) Fax (817)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900"

Transcription

1 PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip Code: Address: Please list telephone numbers below that are okay to call: Home: Work: Cell: Marital Status (please circle): Single Married Divorced Other Relationship to insured (please circle): Self Spouse Child Other Status (please circle): Student Full-time Student Part-time Employed Full-time Employed Part-time Retired Other If employed, name of employer: Appointment : Provider/Therapist Name: INSURED S INFORMATION Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip Code: Address: Home: Work: Cell: Name of Insurance Carrier: Insured Insurance ID #: Group/Policy/Account #: Employer Name: ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION TO INSURANCE COMPANY I HEREBY ASSIGN, TRANSFER AND SET OVER TO Provider all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine benefits, including medical, surgical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that this order does not relieve me of my obligation to pay such bill if not paid by insurance company, or of any balance due payments by my insurance company. PRINTED NAME of Patient/Guardian SIGNATURE of Patient/Guardian To be completed by Healthcare Provider/Office Manager Axis 1 - Axis 2 - Axis 3 - Copy of Office/Financial Policy give to: Client; Parent/Guardian; Client Ref

2 PATIENT INFORMATION Referral source: Your main concern: Previous treatment or therapy? Yes No If yes, with: When? Do you currently experience difficulty in any of the following? Anxiety/Tension Frequent Headaches Attention Span Guilt Sleep Problems Confusion Isolation Fears Weakness Depression Dizziness Difficulty Concentrating Appetite Changes Suicidal Thoughts Memory Anger Nausea Nightmares Mood Swings Fatigue Alcohol Usage: Never Socially Occasionally Weekly Daily List your current medications: 1. Name of medication: Dosage: Times per Day: 2. Name of medication: Dosage: Times per Day: 3. Name of medication: Dosage: Times per Day: 4. Name of medication: Dosage: Times per Day: 5. Name of medication: Dosage: Times per Day: Do you use non-prescription drugs? Yes No If yes, please list: Other people living at home: Recent Changes: Identify your strengths: Emergency Contact Information: Name of Emergency Contact: Relationship: Address: Home #: Work #: Cell #:

3 PRIMARY CARE PHYSICIAN (PCP) INFORMATION Most insurance companies required Primary Care Physician information for coordination of care. 1, Do you have any medication allergies? Yes No If Yes, please list medications to which you are allergic: 2. Do you have a Primary Care Physican (PCP)? Yes No If No, no additional information on this page is needed. If Yes, please give the following information and continue to 3a or 3b: Name of PCP City 3a. I decline to have my Primary Care Physician contacted. OR 3b. Consent for Release of Confidential Information to Primary Care Physician: I, hereby authorize Your Name Name of Grapevine Behavioral Healthcare Provider to disclose to my Primary Care Physician,, Name of Physician, Address, City, State, Zip Code all clinical information about me as may be necessary to permit my Primary Care Physician to monitor the continuity of my care and to inform my Primary Care Physician of my health status. This authorization becomes effective, 201 and may be revoked by me in writing at any time, except to the extent of action already taken. Unless earlier revoked by me, this authorization automatically terminated the earliest of six months from the effective date, or the term coverage of my benefit plan. I understand that this authorization does not extend to the release of any HIV/AIDS information unless I have also placed my initials here:. I further understand that the information authorized by the Release will be released to the authorized recipient only, for the purpose noted above. I understand I (or my legal representative) am entitled to a copy of this authorization form for my records. Witness This portion to be completed by Office Personnel only. To: From: Re: : In an effort to coordinate care, I want to inform you that your patient,, was referred to me by for treatment of. Care is being delivered in the following setting: Intensive Outpatient Program Partial Hospital Program Outpatient Inpatient Unit Residential Treatment Program Other (specify) The treatment plan consists of the following modalities: Individual Psychotherapy Group Therapy Family Psychotherapy Other (specify) Please call me at (817) if you have any further questions.

4 OFFICE AND FINANCIAL POLICY CHARGES: The fee for psychotherapy appointments are scheduled at the rate of $ for the initial session and $ for each additional session. Group therapy session rate is $ Additional time spent in the session will be charged on prorated basis, however, please understand that there are other appointments scheduled after your session so extended time is usually not available. Session time is 45 minutes, the treatment time common for psychotherapy. Prorated charges will be made for phone consultations after five minutes. These charges are not billed through insurance companies and are the responsibility of the patient. CANCELLATION POLICY: A fee of $90 will be charged for appointments not kept or for appointments cancelled without a 24-hour notice. It is required that this fee be paid or payment arrangements are made prior to your appointment. Our voice mail is available 24 hours a day which allows you to leave a message at any time. Please understand that this is an office policy and is not individually negotiated by your therapist. Excessive cancellations and missed appointments may result in loss of regularly scheduled appointment time or possibly the termination of treatment. Usually there is a waiting list of clients wanting to schedule appointments and it is important for us to accommodate these clients as well. INSURANCE VERIFICATION AND AUTHORIZATION: As a courtesy, we will verify your insurance coverage and benefits. It is recommended that you contact your insurance company directly to clarify what services are covered. If pre-authorization is required for outpatient mental health services through your insurance company and/or Employee Assistance Program (EAP) visits, it is your responsibility to contact your insurance company or EAP provider to obtain this authorization. Failure to obtain an authorization number may result in your responsibility for all charges. We will bill your primary insurance only. We can provide information for you to bill your secondary insurance upon request. MANAGED CARE CLIENTS: Clients are responsible for the payment of copays at the time of each visit. If you exhaust your benefits, you may make arrangements with the office manager to personally pay for your sessions. PAYMENT: Payment is due at the time services are rendered unless other arrangements are made or if you are referred by a managed care or EAP program that covers all of your charges. Cash, checks, Visa and MasterCard are all accepted. Payment is expected at each office visit. In most cases, full payment is expected. Copayments and negotiated/managed care rates are required at the time of service. There is a $35 charge for all returned checks. Any balance not paid by your insurance company becomes your responsibility, including deductibles, exhausted benefits and pre-existing conditions. You are encouraged to contact your insurance company to be sure that you understand which services will be covered by outpatient mental health services. Please inform us if there is a situation that makes it difficult to pay your bill. Payment arrangements can be made in most cases and we are willing to work with you if necessary. An itemized statement will be mailed to you. COLLECTION OF UNPAID BALANCES: A statement of fees owed will be mailed to you as they occur. Please do not ignore these statements. Any unpaid fees may be referred to a collection agency after 45 days. If this is necessary, an additional charge of $25 will be added to your account to cover the cost of this service. FILE COPIES: There is a $45 charge for copying of files sent by an outside source. To release records, your account must be paid in full and appropriate release forms must be signed. EMERGENCY SITUATIONS: A licensed therapist is on call for clinical emergencies at all times. The emergency phone number is (817) Please leave your name, number, the nature of your emergency and the name of your therapist. Your call will be returned as soon as possible. If you do not get a return call after 15 minutes, please call again. In some cases, your personal therapist may not be available, but the therapist on call is available to help you. If a crisis occurs, please contact our office immediately so that you can get the support you need. DIAL 911 FOR ALL LIFE THREATENING EMERGENCIES.

5 OFFICE AND FINANCIAL POLICY (continued) CONFIRMATION OF APPOINTMENTS: The office does not make confirmation calls for your appointments. Please make a note of your appointment time and date. LEGAL FEES: There therapists at Grapevine Behavioral Healthcare Associates are not forensic therapists, therefore we do not specialize in court testimony. However if a therapist is subpoenaed or if therapy records are requested by the court or an attorney, the information will be provided whether or not it is favorable to the undersigned. In the event of a subpoena or request by an attorney or patient, it is fully understood that the patient will be billed $ an hour for reports, court appearances, travel and availability. If therapists are scheduled to appear and are available (i.e. cancels other appointments scheduled for that day) and the court is cancelled, the patient will be billed $ hourly for availability with a minimum of two hours paid in advance. These charges are not covered by insurance companies and are billed directly to the patient. It is required that payment is made prior to the court date and a minimum of two hours ($400.00) is paid in advance. ARD MEETINGS AND SCHOOL CONFERENCES: You can request that your therapist attend ARD meetings at your child s school to participate in educational planning and adjunct treatment. The fee is $ per hour including travel time. Your therapist may also be available for phone conferences for the same rate. These charges cannot be billed to your insurance company. EMERGENCY TELEPHONE NUMBERS: We are not equipped to provide emergency psychiatric treatment but the following facilities are available for emergency services: Baylor Hospital, Grapevine (817) Denton Regional Medical Center (940) HEB Springwood, Bedford.(817) Millwood Hospital, Arlington.(817) Cooks Childrens Hospital, Fort Worth..(682) Green Oaks Hospital, Dallas..(972) John Peter Smith...(817) Seay Center, Dallas (children and adolescents only) (972) DIAL 911 FOR ALL LIFE THREATENING EMERGENCIES. I have read, understand and agree to this financial policy and acknowledge that I have received a copy. I authorize the release of medical and other information necessary to process to insurance claims. I authorize payment of insurance benefits to Grapevine Behavioral Healthcare Associates and/or my specific provider. I will be responsible for any fees not covered by insurance. In the event that my account becomes past due, I understand that interest and collection fees may be added to my balance and an outside collection agency may be utilized. Printed Name of Patient or Parent/Guardian

6 RECEIPT OF HIPAA INFORMATION I hereby acknowledge that I have read and understand the PRIVACY PRACTICES notification as prescribed by HIPAA. I understand that HIPAA places restrictions on the release of psychotherapy notes to patient or family. Further, I understand that I may request additional information by contacting the U. S. Department of Health and Human Services at (877) Please list any others you authorize information to be released to: Printed Name of Patient or Parent/Guardian I am the (circle one) Patient Parent Guardian Other (specify) Witness

7 CREDIT CARD AUTHORIZATION I,, authorize Grapevine Behavioral Healthcare Associates to use the information and credit card numbers I have provided them to make payments for services rendered at their facility including copayment, coinsurance, No Show charges and Late Cancellation charges. If at any time I wish to terminate this agreement, Grapevine Behavioral Healthcare Associates will be notified and my credit card information will be destroyed. Witness (date signed OR verbal authorization give to Grapevine Behavioral Health Associates) Credit Card (circle one): MasterCard Visa Name exactly as it appears on the card: Credit Card Number: Expiration :

Warner Family Counseling

Warner Family Counseling Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact

More information

Patient Information Form Trinity Wellness Center. Insurance Information

Patient Information Form Trinity Wellness Center. Insurance Information Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student

More information

The Healthy Mind PSYCHIATRIC SERVICES

The Healthy Mind PSYCHIATRIC SERVICES The Healthy Mind PSYCHIATRIC SERVICES 900 Straits Tpk Suite D Middlebury, CT 06762 New Patient Registration: Patient s First Name Last Name Patient s Telephone: Home Cell Email: Patient s Date of Birth:

More information

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

Nichol A. Moses, Psy.D., NCSP

Nichol A. Moses, Psy.D., NCSP PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to

More information

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515 : / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell

More information

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

More information

Ellyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com

Ellyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com Date CLIENT INFORMATION Client Name Address City State Zip Code Primary Contact Ph # Cell Home Work Secondary Ph # Cell Home Work Email Address Do you text? Yes No Birth date Social Security Number Occupation

More information

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip Today s Date: / / / / Full Legal Name (First, Middle, Last) Date of Birth Age Social Security Number Marital Status Address City State Zip Out of State Address Phone: Home ( ) - Cell ( ) - Email: PREFERRED

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

New Perspective Counseling Services Child/Teen Intake Form

New Perspective Counseling Services Child/Teen Intake Form Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470 PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone

More information

Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328

Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.

More information

Mosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION

Mosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION NEW CLIENT INFORMATION (Please Print) / / Client Name M/ F of Birth Address City/State Zip Home ( ) Work ( ) Cell ( ) Email Address: (Circle One) Minor Single Married Divorced Separated Widow Living Together

More information

Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION

Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION PLEASE PRINT CLEARLY DATE NAME ADDRESS DX (OFFICE USE ONLY) CITY STATE ZIP OCCUPATION HOME PHONE EMAIL WORK PHONE CELLULAR

More information

James A. Purvis, Ph.D. Psychotherapy Services Agreement

James A. Purvis, Ph.D. Psychotherapy Services Agreement James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist

More information

NEW PATIENT INFORMATION CONSENT AND AGREEMENT

NEW PATIENT INFORMATION CONSENT AND AGREEMENT NEW PATIENT INFORMATION CONSENT AND AGREEMENT PSYCHOLOGICAL SERVICES. Psychological services vary depending on the reason for referral. In all cases, the initial appointment is set up with the parents/guardians

More information

RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:

RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number: RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX 77030 PATIENT INFORMATION Patient's Legal Name: Date of Today's Visit: Social Security # Date of Birth: Age: Sex: M F Martial Status: S

More information

Client Information (Please Print) Therapist name: Date: Social Security# Work Phone (Please circle your preferred number?)

Client Information (Please Print) Therapist name: Date: Social Security# Work Phone (Please circle your preferred number?) Client Information (Please Print) Therapist name: Date: Name Last First Initial Street Unit # City/State/Zip Employer Email (Please provide email address. Will only be used for clinic purposes.) Social

More information

Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398

Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398 Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398 Thank you for filling out this form. All information will be kept in strict confidence. Name Date Address

More information

Keweenaw Holistic Family Medicine Patient Registration Form

Keweenaw Holistic Family Medicine Patient Registration Form Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend

More information

PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #

PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone # Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

Declaration of Practices and Procedures

Declaration of Practices and Procedures LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased

More information

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478

More information

SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)

SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial) Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples

More information

Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.

Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling. Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.org I. Initial Client Information Date: Social Security

More information

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments

More information

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance. Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work

More information

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 Dear Client: It is a pleasure to have you in our practice. We appreciate the opportunity

More information

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:

THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp

More information

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:

More information

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078 Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd

More information

Jodi L. Ceballos, Psy.D. Clinical Psychologist

Jodi L. Ceballos, Psy.D. Clinical Psychologist Hello, my name is Dr. Jodi Ceballos and I am a Licensed who recently relocated to Del Rio. I offer psychological and psycho-educational testing services, as well as individual, couples, and family therapy

More information

Patient Registration Form (ecw) (First) (MI) Previous Name. Address

Patient Registration Form (ecw) (First) (MI) Previous Name. Address Patient Registration Form (ecw) PATIENT INFORMATION (Please Print) Dr. Miss Mr. Mrs. Ms. Patient's Name (Last) (First) (MI) Previous Name Address City, State ZIP Check the best contact number q Home Phone

More information

Reason(s) For Referral: Current medications:

Reason(s) For Referral: Current medications: 1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:

More information

Arrive 15 minutes before your scheduled appointment time.

Arrive 15 minutes before your scheduled appointment time. Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist

More information

Marian R. Zimmerman, Ph.D.

Marian R. Zimmerman, Ph.D. Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date

More information

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

More information

Piedmont Psychiatric Services

Piedmont Psychiatric Services Piedmont Psychiatric Services 2094 Woodruff Rd. Greenville, SC 29607 Tony R. Goodbar, MD Jeffrey K. Smith, MD Joseph A. Friddle, PA-C James M. Harbin, M.Ed., LPC Michael D. Smith, MA, LPC Albert C. Bennett,

More information

OUTPATIENT SERVICES CONTRACT

OUTPATIENT SERVICES CONTRACT OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred

More information

Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677

Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:

More information

AGREEMENT AND INFORMATION

AGREEMENT AND INFORMATION AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.

More information

PRE-SCREENING CHECKLIST

PRE-SCREENING CHECKLIST PRE-SCREENING CHECKLIST Please provide the following information and mail, email or fax to: Positive Synergy Corp. 45 Spring Hill Ave. Northbridge, MA 01534 Email: intake@positivesynergyasd.org Fax: (508)-401-2696

More information

HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY

HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY HΨC HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY 5237 SUMMERLIN COMMONS BLVD, SUITE 116 FORT MYERS, FLORIDA 33907 PHONE: 239.274.PSYC (7792) FAX: 239.247.5344 Informed Consent for Financial Responsibility & Psychological

More information

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed) Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.

More information

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:

More information

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy) HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register

More information

PATIENT S NAME: DOB: PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN S EMPLOYER: SCHOOL: CONTACT: GRADE:

PATIENT S NAME: DOB: PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN S EMPLOYER: SCHOOL: CONTACT: GRADE: FAMILY PSYCHOLOGY ASSOCIATES NEW PATIENT INFORMATION SHEET PATIENT S NAME: DOB: ADDRESS: (street) (apt#) (city) (zip) PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN

More information

If physical therapy is being sought due to an accident, please indicate the and of the accident

If physical therapy is being sought due to an accident, please indicate the and of the accident 2919 S. 120 th St. Omaha, NE 68144 Office Phone: (402) 504-3535 Cell Phone: (402) 630-9756 Fax: (402) 934-3866 OUTPATIENT THERAPY TREATMENT AGREEMENT If physical therapy is being sought due to an accident,

More information

LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062

LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 PHONE: 847.497.8378 LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 Intake Form Date of Intake: Caller: DRLEIGHWEISZ.COM Referral Source: May I thank referral

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE: PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY

More information

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity

More information

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip.  Address PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH

More information

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a

More information

The Center for ADHD, Inc.

The Center for ADHD, Inc. Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address

More information

Patient Registration Please Print Patient Name Last First Middle

Patient Registration Please Print Patient Name Last First Middle Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact

More information

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone

More information

INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST)

INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST) INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST) Last Name: Dr. Mr. Mrs. Ms. First Name: Middle Initial: Date of Birth: Home Address: City: Zip Code: Social

More information

Associates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909

Associates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909 Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:

More information

Stonebriar Psychiatric Services, P.A. Policies

Stonebriar Psychiatric Services, P.A. Policies OFFICE HOURS: Stonebriar Psychiatric Services, P.A. Policies Monday through Thursday, 8:00 a.m. to 4:00 p.m. The office is closed major holidays and the week between Christmas Eve and New Year s. APPOINTMENTS:

More information

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

More information

Syeda N. Sultana, M.D. Board Certified Child, Adolescent & Adult Psychiatrist

Syeda N. Sultana, M.D. Board Certified Child, Adolescent & Adult Psychiatrist Patient's First Name: Middle Name: Last Name: Sex: Marital Status: of Birth: Social Security Number: Patient's Address: Home Phone: Email Address: Primary Care Physician: Pharmacy: Mobile Phone: Referred

More information

I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat.

I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat. CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC Consent to Evaluate and Treat Patient: Age: Date of Birth: Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Business/Cell

More information

REGISTRATION AUTISM TREATMENT SERVICES

REGISTRATION AUTISM TREATMENT SERVICES 559 Zor Shrine Place Madison, WI 53719 P: 608.833.0123 F: 608.833.0126 www.ids -wi.com CLIENT INFORMATION (First, MI, Last) (Street, City, State, Zip) REGISTRATION AUTISM TREATMENT SERVICES of Birth Home

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital

More information

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)

More information

Orthopedic Initial Questionnaire

Orthopedic Initial Questionnaire Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Psychological Services Contract

Psychological Services Contract Azmaira Maker, Ph.D. Licensed Clinical Psychologist (PSY 21570) 12625 High Bluff Drive, Suite 104 San Diego, CA 92130 Tel: (858) 531-1122 Fax: (866) 861-7731 www.drmaker.net Thank you for inquiring about

More information

Arie Poot M.A., M.Div. 117 North 1st Mount Vernon, WA (360)

Arie Poot M.A., M.Div. 117 North 1st Mount Vernon, WA (360) Arie Poot M.A., M.Div. 117 North 1st Mount Vernon, WA. 98273 (360)-421-2436 APPLICATION FOR THERAPY Client Name: Spouse Date of Application: / / *Client s Birthdate: / / Address: City Zip Phone (Day):

More information

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)

More information

Alison J. Bomba, Psy.D.

Alison J. Bomba, Psy.D. Alison J. Bomba, Psy.D. Licensed Psychologist OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please

More information

FAMILY PRACTICE PATIENT REGISTRATION FORM

FAMILY PRACTICE PATIENT REGISTRATION FORM FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First

More information

Wake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587

Wake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587 Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor

More information

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment. Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical

More information

Optimum Performance Physical Therapy, LLC

Optimum Performance Physical Therapy, LLC Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Email: Employer Name/ Address: Referring Physician: (P)

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

P.S. Please remember to bring your completed forms to your office visit!

P.S. Please remember to bring your completed forms to your office visit! Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office

More information

Client Information Packet

Client Information Packet Phone: 303-569-4588 Office locations: Email: tony@equinoxcounselingllc.com Highlands Ranch Medical Plaza II: 9331 South Colorado Blvd., Suite 60 Website: www.equinoxcounselingllc.com Highlands Ranch, CO

More information

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH# Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:

More information

Counseling Intake Form (Each person attending therapy should complete a form)

Counseling Intake Form (Each person attending therapy should complete a form) Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay

More information

Orthopedic Initial Questionnaire. Date: Weight:

Orthopedic Initial Questionnaire. Date: Weight: Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997

Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997 Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997 Informed Consent & Agreement for Psychotherapy Services Effective July 7,

More information

I have received a copy of the Notice of Privacy Practices True Health.

I have received a copy of the Notice of Privacy Practices True Health. Sign-in Time: I have received a copy of the Notice of Privacy Practices True Health. Signature of Patient/Patient Representative Relationship of Patient Representative to Patient 2400 State Road 415 11881-A

More information

UPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:

UPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth: COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle

More information

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C. LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME

More information

Welcome to Tri-State Rehab Services

Welcome to Tri-State Rehab Services Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely

More information

PATIENT INFORMATION Please complete for self or minor child responsible party information below. Street Apt. City State Zip

PATIENT INFORMATION Please complete for self or minor child responsible party information below. Street Apt. City State Zip Name: Address: E-mail: Phone numbers: Lisa Dungate, Psy.D., M.A. Mental Health Counseling PATIENT INFORMATION Please complete for self or minor child responsible party information below DOB: Street Apt.

More information

Sincerely yours, Rev. 06.10

Sincerely yours, Rev. 06.10 Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy

More information

Patient Financial Policies

Patient Financial Policies Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID 82301 208-235-5910 Fax 208-235-5920 Thank you for choosing Diabetes & Internal Medicine Associates,

More information

PATIENT FINANCIAL RESPONSIBILITY STATEMENT

PATIENT FINANCIAL RESPONSIBILITY STATEMENT PATIENT FINANCIAL RESPONSIBILITY STATEMENT Thank you for choosing Medical Associates Clinic, P.C., as your healthcare provider. The medical services you seek imply an obligation on your part to ensure

More information

When you arrive for your first appointment, please bring the following with you:

When you arrive for your first appointment, please bring the following with you: 115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your

More information

Physical Occupational and Speech Therapy Patient Information Sheet

Physical Occupational and Speech Therapy Patient Information Sheet Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY

More information

Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT

Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT PROFESSIONAL SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Lifeway Information Form

Lifeway Information Form Lifeway Information Form Patient Name: First MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: Please circle home cell

More information