EmailMe Form - Full Potential Counseling New Client Intake Form

Demographics

Client Name *

First Last

Date of Birth *

MM / DD / YYYY

SSN *

Do not include dashes

Client Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Phone Number: *

### - ### - ####

May we leave a message at this number? *

Yes

No

Gender *

Male

Female

Marital Status *

Insurance

Do you have current Insurance coverage *

YES

NO

If no insurance, will you be utilizing private pay?

YES

NO

Name of Insured? *

First Last

The “insured” is the person who owns the policy or is the employee to whom a group policy is applicable

Client relationship to insured *

Self

Spouse

Child

Other

Primary Insurance Plan Name *

Primary Insurance ID number *

Primary Insurance group number *

Secondary Insurance *

If not applicable, type N/A.

Secondary Insurance ID number

If not applicable, type N/A.

Secondary Insurance group number

If not applicable, type N/A.

File Upload

Please include a photo of the front and back and each insurance card.

Scheduling

Please indicate what days/times are preferred for appointments? If you do not have availability on a particular day, please type N/A.

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Sat/Sun *

I authorize the release of any medical or other information necessary to process insurance claims. I further authorize the payment of medical or insurance benefits and authorize this provider to obtain or release therapy records and treatment plans to my insurance company for the purpose of evaluation, treatment and payment.

Signature *

Clear