CHARI D. VANDEVER, M.A., LPC Psychotherapist 5262 S. STAPLES, SUITE 329 PHONE: (361) 653-3010 CORPUS CHRISTI, TEXAS 78411 EMAIL: [email protected]

------Patient Intake Information Personal Information

Client’s Name: ______Today’s Date: ______Birthdate: ______Age: ______City of birth: ______Address: ______City/State/Zip: ______How did you hear about us? Internet/Insurance Company/Physician/Other: ______Name of agency or physician: ______Employer: ______Occupation: ______If client is a minor, Name of Guardian: ______Guardian Phone: ______Address of Guardian: ______ALL COURT ORDERS REGARDING CUSTODY OF A MINOR MUST BE BROUGHT TO THE FIRST APPOINTMENT If Client is Student, School Attending: ______Grade______Home Phone: ______Work Phone: ______Cell Phone: ______Email: ______Where would you like us to leave reminder messages: Cell Phone/Email/None In the event of an emergency with you, whom should we contact: Name: ______Relationship: ______Work #: ______Home #: ______Responsible Party/Insured

Name: ______Relationship to Patient: ______Birthdate: ______Insurance ID: ______Address: ______City/State/Zip: ______Employer: ______Work Phone: ______Insurance: ______Primary? ______Other Health Insurance: ______Secondary? ______Authorization and Release I authorize the release of any information including the diagnosis and the records of any treatment rendered to me or to my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the provider of care insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or for my dependents. I give Chari D. Vandever, LPC the right to seek the services of a bill-collecting agency in efforts to collect fees that my insurance company has not paid and that I have not paid to her for services rendered and/or for cancelled or missed appointment ______Signature of Patient or Parent of Minor Child Date