Sample New Client Information Form - Insurance

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NEW CLIENT INFORMATION-Insurance
Date: ___________________
Client Name: ________________________________________
Date of Birth: ______/_____/______
If minor; name of Parent/Guardian: ___________________Parent Cell Phone: ____________________
Home Phone: _______________ Work Phone: __________________ Cell Phone: _________________
May we contact you and leave messages at these phone numbers?
Yes
No
Home Address: ______________________________________ City: ________ State: ____ Zip: ______
May we mail information to this address:
Yes
No
If “no” please give mailing address: ________________________________________________________
Email: _______________________________________May we email information to you?
Yes
No
Sex:
Female
Male
Marital Status:
Single
Married
Other
Employed
Yes
No
Current School attending (if minor): _________________________________ Grade ______________
FINANCIALLY RESPONSIBLE PARTY
Name: ________________________________________________ Date of Birth: ______/_____/______
Employer: ______________________
Occupation: _____________________________________
Address
:_________________________________ City: __________ State: ____ Zip: ______
(if different)
Social Security #:
______/_____/______ Contact No. (
)____________________________
if different
Sex:
Female
Male
Marital Status:
Single
Married
Other
ADDITIONAL PATIENT INFORMATION
O
How were you referred to our office?
Internet
Insur.Website
Doctor
Other ______________
Who may we thank for referring you? __________________ Reason for referral: _________________
Previous Therapy/Counseling:
Yes
No
If “yes”; with whom: ________________________
Family Physician: ___________________________ Date of last Physical (client): __________________
Overall Health: ______________
Any chronic health conditions? : ___________________________
Current Medications: ____________________________________________________________________
List names/age of immediate family members or others living in the home: _______________________
_______________________________________________________________________________________

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