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Name of Patient to be treated*:
Patient Age*:
Patient Birth Date*:
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Best day and time to schedule appointments:
Tell us about what is going on:
Has individual been in treatment in the past 6 - 12 months for the same issues?
Where has prior treatment been conducted?
Is patient currently taking medications? Yes      No
Will you be using Insurance? Yes      No
Are you interested in e-Therapy? What's this? Yes      No
If yes, please take a minute to pre-authorize your visit by filling out the following information
(you will need your insurance card):
Name of Patient:
Name of Subscriber:
Home Address:
Home City:
Home State:
Home Zip Code:
Home Phone Number:
Preferred Contact Number:
May we Contact you at Work? Yes      No
May we Contact you at Home? Yes      No
Insurance Company:
Insurance Member ID:
Insurance Contact Number:
Subscriber (the person who carries the insurance):
Subscriber Address if different than patient's:
Subscriber City:
Subscriber State:
Subscriber Zip Code:
Subscriber’s Employer:
Employer’s Address:
Group Number:
Is treatment pertaining to an accident or
work related injury?		 Yes      No
Pediatrician/Primary Care Doctor:
Pediatrician's Town:
School:
Are you aware of any deductibles? Yes      No
Are you or an immediate family member a veteran? Yes      No
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