* Fields marked with a red asterisk are required fields Please enable JavaScript in your browser to complete this form.CLIENT DETAILSClient Name *FirstMiddleLastClient Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Phone *Accepts Text Messages?YesNoPermission to leave a message?YesNoSecondary Phone *Accepts Text Messages?YesNoPermission to leave a message?YesNoClient Email *INSURANCE PROVIDERMember's Name *Member's Employer *Insurance Carrier *Group Number *Member's ID Number *Member's Date of Birth *Client's ID Number *Client's Date of Birth *Client's relationship to memberSelfChildSpouseRefer to your insurance card for the following phone numbers: Member ServicesBehavioral / Mental HealthProvider HotlineClient's GenderClient's Religious Preference (if you want us to know)Client's Marital Status *SingleMarriedDivorcedWidowedSeparatedClient's Marital StatusSingleMarriedWidowedSeparatedDivorcedToday's Date *Date of first scheduled appointment *Whom can we thank for your referral?Internet/Search EngineFriend ReferralSocial MediaInsurance CompanyOtherEmergency Contact *Emergency Contact Phone * Member of we Relationship to Emergency Contact *Session Fees & Copays: Due at the beginning of each appointment. Signature * Clear Signature Today's Date *Submit
