NEW CLIENT FORM CLIENT NAME: Date of Birth: Address: Town: Home Telephone Cell Telephone Gender Recognized by Ins. Co.:

SS#: State: Email: Work Telephone ___Male ___ Female

Zip:

CLIENT INFORMATION: COMPLETE FOR ALL CLIENTS AS APPLICABLE Parent/Guardian: Legal Address: Mailing Address: Primary Health Care Provider:

Phone #:

Phone #:

IN CASE OF AN EMERGENCY CONTACT: NAME______________________________________ CONTACT TELEPHONE:________________________________________

BILLING INFORMATION ICD - 10 Code (# & description) Place of Service: ___Office ___Client’s home

___Other

PRIMARY INS. CO.: _________________________________PHONE #:_______________________________ SUBSCRIBER NAME (If other than client):______________________________________________________ SUBSCRIBER DATE OF BIRTH: ____________________ SUBSCRIBER SS#: ________________________ POLICY#: ____________________________________

GROUP#:_________________________________

DEDUCTIBLE AMOUNT_______________________

CO-PAY:_________________________________

AUTHORIZATION REQUIRED: YES ___ NO___

AUTHORIZATION # _____________________

AUTH. START DATE: _________________________

AUTH. END DATE: _______________________

NUMBER OF SESSIONS ALLOWED: ____________

SECONDARY INS. CO.: ____________________________PHONE #:__________________________________ SUBSCRIBER NAME (If other than client):_________________________________________________________ SUBSCRIBER DATE OF BIRTH: ______________________SUBSCRIBER SS#: __________________________ POLICY#: ____________________________________

GROUP#:___________________________________

DEDUCTIBLE AM’T:___________________________

CO-PAY:___________________________________

AUTHORIZATION REQUIRED:

AUTHORIZATION # _______________________

YES ___ NO ___

AUTH. START DATE: ___________________________

AUTH. END DATE: ________________

NUMBER OF SESSIONS ALLOWED: _____________

Please provide 24 hour notice for cancellations. Otherwise, client is responsible for contracted rate with insurance company or agreed upon rate. By signing below you authorize the Administrator to disclose to your insurance company or other authorized benefits provider all information that is customary and necessary to process your benefits claim. It is understood that this does not guarantee in any way the payment of such a claim; that such payment is solely the responsibility of the client (or parent/guardian) and/or the benefit provider, not the Administrator.

I HAVE READ THIS FORM AND UNDERSTAND ITS CONTENTS. Signature: ____________________________________________Date: _____________________ Parent/Guardian: ______________________________________Date: _____________________