Child Client Intake Form printable pdf download

HOPE COUNSELING CENTERS

Phone: (863) 292-8292

Winter Haven Office

Fax: (863) 292-8283

160 Ave E., N.W.

Winter Haven, FL 33881

CHILD CLIENT INTAKE FORM (Please print)

Name: ___________________________________________________________________Today’s Date: _______________________

Address: _______________________________________________ City: _____________________ State: ______ Zip: ___________

Sex: □ Male □ Female Date of Birth: ____________________ Age: _______ Home phone: ______________________________

Mother’s Name: __________________________________________________________ Cell phone: __________________________

Mother’s address: _____________________________________________________________________________________________

Mother’s occupation: ____________________________________________________ Work phone:___________________________

Father’s Name: _________________________________________________________ Cell phone: ___________________________

Father’s address: _____________________________________________________________________________________________

Father’s occupation: ____________________________________________________ Work phone: ___________________________

Insurance Information:

Insurance Company:

Identification Number:

_____________________________________________

__________________________________

Mailing Address:

Telephone #:

___________________________________________________________

________________________________

Insured Party (Subscriber Information):

Last Name:

First:

Date of Birth:

_________________________________________

_______________________________

__________________

Social Security #:

Relationship to Client:

________________________________

__________________________________________________

Mailing Address:

________________________________________________________________________________________________________

Emergency Contact Information:

Name (Someone not living with you): ________________________ Relationship: ______________________Home Phone #: __________________

Consent For Treatment and Authorization for Assignment of Benefits and Information Release

I hereby give consent to Hope Counseling Centers (HCC) to provide whatever treatment they may deem necessary to the client above. I understand that I am

responsible for charges incurred for services. I understand I am responsible for charges not covered by the insurance policy, and should it become necessary to collect

these charges through an attorney or other collections process, I shall be responsible for all court costs, attorney’s fees and a collection of expenses of no more than 30%

of referred balance.

I hereby request payment of authorized insurance benefits and/or any other, including supplemental insurance benefits for me to be paid directly HCC for any services

furnished by HCC. I authorize HCC and staff to release to my insurance carrier and its agents any information concerning health care advice, treatment or supplies

provided, needed to determine those benefits or the benefits payable for related services.

_________________________________________

________________

Guardian Name

Guardian Signature

Date

_________________________________________

________________

Guardian Name

Guardian Signature

Date

Offices: