CLIENT INFORMATION

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(203) 455-8375

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THIS SHEET MUST BE FILLED IN COMPLETELY

YES

NO

Client's Social Security Number

Today's Date

Client's First Name

MI

Client's Last Name

Client's Date of Birth * required

Client's Gender

Client's Address

Client's Address Line 2

Client's City

Client's Region/State

Client's Postal / Zip code

Client's Country

Client's Phone

Client's Email

GUARDIAN INFORMATION

Guardian Name

Guardian Phone

Guardian Email

Guardian Street Address

Guardian Street Address Line 2

Guardian City

Guardian State

Guardian Country

Guardian Zip Code

Guardian Date of Birth

Guardian SSN

Emergency Contact

Primary Care Physician

Emergency Contact Phone

Relationship to Client

Primary Care Physician Address

Please describe your present reason for seeking a therapist:

Have you ever met with a social worker, psychologist, psychiatrist, or any mental health professional? * Required

YES

NO

Are you currently being treated by any mental health professional or taking any psychiatric medications? * Required

YES

NO

If yes, name the prescriber, name of medication, dosage, start date of medication and reason medication was prescribed.

Have you ever been hospitalized for mental health reasons? * Required

YES

NO

If yes, what are the approximate dates and reason for admission?

Do you have any significant medical issues?you ever been hospitalized for mental health reasons? * Required

YES

NO

If yes, please describe those medial issues

INSURANCE INFORMATION

Subscriber's Name

Subscriber's Phone

Subscriber's Street Address

Subscriber's City

Subscriber's State

Subscriber's Zip Code

Subscriber's Date of Birth * required

Subscriber's SSN

Please email a copy of your medical insurance card (including back) and drivers license, for insurance verification to: info@bestpracticepsychotherapy.com

Primary Insurance Carrier Name

Secondary Insurance Carrier Name

Primary Insurance Member/Policy ID

Secondary Insurance Member/Policy ID

Primary Insurance Group No.

Secondary Insurance Group No.

I do not have medical insurance coverage.

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