Psi Client Information Form printable pdf download

PSI Client Information Form

Date: ______________

Client Name: ___________________________ Sex: M F Date of Birth: ________________

Client Address: _______________________________________________________________

Street

City

State

Zip Code

May we correspond by email? Y N

Email address: ________________________________

Client Home Phone:____________Daytime Phone:_____________Cell Phone:_____________

Marital Status: Single

Married

Divorced

Domestic Partner

Widowed

Client SSN: ______________________

Person filling out form, if not client: ______________________ Relationship to client: ________

Primary Care Physician: _________________________________ Phone: _________________

Emergency Contact: ____________________________________ Phone: _________________

Please fill out all of the following information even if a copy of your insurance card is attached:

Primary Insurance: ____________________________________ Phone: _________________

Authorization #: ___________________ Policy Holder SSN: ___________________________

Insurance Billing Address: _______________________________________________________

Name of Policy Holder Exactly as It

Appears on the Card: _______________________________ Date of Birth: ________________

Policy Holder I.D. #: ___________Group #: ___________ Group Name: __________________

Policy Holder Mailing Address (if different from client’s): _______________________________

Policy Holder Phone: _____________________ Relationship to Client: ___________________

Cash Pay: Yes

EAP: ______________________ EAP Authorization #: __________

How did you hear about PsychStrategies, or who referred you to us? _____________________

Are you involved in any legal proceedings (e.g. Worker’s Compensation Claim, child custody

dispute, etc) which may involve your therapist?

Yes

If yes, please describe:

I authorize my insurance carrier to pay PsychStrategies (please sign):

____________________________________________________________________________

For Clinician use Only (please print)

Clinician Name: _______________________ # ____ Dx: _______ Copay due/session: ______

Rev 06.21.07

Rev 06.19.12

House/Forms/Client Information

Psi Client Information Form