Complete New Paperwork

Type of Services Sought
Please check all services you are interested in at this time
Individual Therapy/Counseling
Couples Therapy/Counseling
Family Therapy/Counseling
Psychological Testing/Assessment
Drug/Alcohol Evaluation
Child Custody Evaluation
Other Service

Demographic Information
Name of Patient:

Patient Address (Street, City, State, & Zip):

Patient Phone Number:

Patient Email Address:

Marital Status of Patient:

Date of Birth of Patient:

Employer of Patient (if applicable):

School Patient Currently Attending (if applicable):

Insurance & Financial Information
Name of person responsible for medical bills:

Name of Insurance Provider:

Insurance Provider Phone Number:

Member ID Number:

Group ID Number:

Name of policy holder/insured:

Date of birth of policy holder/insured:

Claims Address (find on back of your insurance card):

Emergency Contact
Name & phone for person we should contact in case of emergency:

Who referred you to us?:

If Patient is Under Age 18: Name, Address, & Phone of Mother:

If Patient is Under Age 18: Name, Address, & Phone of Father:

If Patient is Under Age 18: Please note who has legal custody of this child:

To schedule a free phone consultation or appointment, please email us or call (630)777-7113.