Patient Face Sheet - Child And Adolescent Psychiatry Consulting

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Child & Adolescent Psychiatry Consulting LLC
DBA
Behrend Psychology Consultants
/
Horses Treat
3930 8
th
St. So. Ste.101,Wis.Rapids, WI 54494
M407 Hwy 97, Marshfield, WI 54449
715-423-2030 ; Fax: 715-423-2032
715-318-0047 ; Fax: 888-485-4412
office@drjenna.net
office@drjenna.net
drjenna.net
!
Patient’s Name
Date of Birth
:_________________________________________________________
:_________________
Address:______________________________________________Social Security #___________________
City_____________________________State__________Zip___________ Home Phone:______________
Email: _________________________________________________ Cell Phone: __________________
Marital Staus:_____________________________Employer:_____________________________________
Occupation:_________________________________________Work Phone:________________________
Spouse Name (
):___________________________________Date of Birth:____________
or parent, if child
Employer:________________________________Occupation:_______________Work Phone:__________
!
IF PATIENT IS A CHILD: School:____________________Grade:_________Teacher:______________
Responsible Party (will receive the statements)
Relationship to Client:
Self
Spouse
Parent
Other:_______________________
Name: __________________________Home Phone: _________________ Cell: ____________________
Address: ________________________City: ______________________State: _______ Zip: ___________
Employer: _______________________________ Phone: _______________________State: ___________
Emergency Contact: Name:_____________________________Phone:___________________________
May we contact you at home? Yes / No
At work? Yes / No
On Cell Phone? Yes / No
For a reminder call for my appts, please:
Call
Text
Email
I prefer not to have reminder calls_______
May we leave a message at home? Yes / No
At work? Yes / No
On Cell Phone? Yes / No
!
Insurance Information
_____________________________________________
: Name & Address of Company
I.D. #___________________________________Group #________________________________________
Name of Insured:__________________________Birthdate:________Address:_______________________
Employer:_______________________________Social Security #_________________________________
Medical Assistance # ________________________County:______________________________________
(Recent copy of MA card required)
Authorization to pay benefits:
I hereby authorize payment directly to CAPC/BPC/HT from my insurance company for services
performed at this clinic. I recognize and accept personal responsibility for the deductible amount and for any balance outstanding after payment of
such insurance benefits. I authorize the release of any medical or other information necessary to process this claim.
Signature: _________________________________________________Date:________________________
(If under 18-parent or guardian signature required)
!
I authorize CAPC/BPC/HT to release information concerning my treatment to the referring physician
__________Yes __________No Signature:_________________________________________Date:__________________________________

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