New-Client-Information

10061 Talbert Avenue, Suite 200, Fountain Valley, CA 92708. Phone: 714-965-3622/ Fax: 714-963-4703

NEW CLIENT INFORMATION

PATIENT NAME:______TODAY’S DATE:______

DATE OF BIRTH:______SEX:______MARITAL STATUS:______

HOME ADDRESS:______CITY/STATE/ZIP:______

HOME PHONE:______BUSINESS PHONE:______

CELL PHONE:______PATIENT SS#:______

STUDENT STATUS: _____Non Student _____Full Time _____Part Time _____Unknown

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Person financially responsible for payment of services and/or subscriber of the primary insurance plan:

SUBSCRIBER:______SS#:______

HOME ADDRESS:______CITY/STATE/ZIP:______

HOME PHONE:______BUSINESS PHONE:______

OCCUPATION/TITLE:______EMPLOYED BY:______

SUBSCRIBER DATE OF BIRTH:______POLICY ID NUMBER:______

INSURANCE COMPANY:______PLAN NAME/GROUP #:______

Subscriber relationship to patient: _____Self _____Parent _____Spouse _____Dependent _____Other

Employment: _____Full Time _____Part Time _____Not Employed _____Retired _____Other

Below For Office Use Only:

Provider Name:______Co Pay:______

Services: _____Individual _____Family _____Testing _____Group _____Other

Diagnosis: Code:______Description:______

THERAPISTS: PLEASE ATTACH COPY OF INSURANCE CARD (front & back) TO THIS FORM.