Birgit Cox, Ph.D., LCPC

Qubenic Yancey, LCPC 1680 E. Gude Dr. Suite 114 Rockville, MD 20850 (443) 814-9769

Private Practice Counseling

PERSONAL INFORMATION PLEASE PRINT

Date ______

Name ______(Last) (First) (Middle)

Age______Date of Birth ______Social Security No.______

How did you hear about my service?______

Home Address______City______Zip______

Home Phone (_____) ______

May I contact you at home? By phone? Yes No By mail? Yes No

Marital Status______Years married______

Employer/School______

Work/School Address______

Work phone: (_____)______Mobile Phone (_____)______

May I contact you at work? By phone? Yes No By mail? Yes No

E-mail address (enter only if I may contact you by E-mail) ______

Emergency Contact - name & number:______

If the client is under age l8, or if a spouse/partner will be involved in therapy, please provide the following information on the parent/spouse/partner:

Family Member’s Employer:______

Work Address______

Work Phone (______) ______

May we contact you at work? By phone? Yes No By Mail? Yes No

of 4 Qubenic Yancey, LCPC 1680 E. Gude Dr. Suite 114 Rockville, MD 20850 (443) 814-9769

Other Household Members Name Age Relationship ______

______

Children Living Outside Home Name Age Name Age

______

Financially Responsible Party (complete this section if patient is a minor or is not responsible for payment):

Name: First______Last______MI______Social Security #:______Date of birth______Address______City______Zip______Employer:______Telephone: (Home)______Work______

Insurance Information: (Complete this section if you will be using any Health Insurance plan as part of your payment for services):

Insurance Co. Name______

Insurance Co. Policy Number______

Insurance Group, Payor, or Plan Number (or name) ______

Insurance Company’s Benefits Phone Number______

Insurance Co. Address (if on your card) ______

Client’s relationship to Insured: ______Self ______Spouse ______Child ______Other

Signature On File & Authorization of Benefits Statement I am the client or a person responsible for the client. I authorize the use of this form on all my insurance submissions for services from this practitioner, Qubenic Yancey, LCPC. I authorize the

Private Practice Counseling release of medical or other information to my insurance company. I understand that I am responsible for my bill. I authorize my therapist to act as my agent in helping me obtain payment from my insurance companies. I authorize payment of medical benefits directly to my therapist. I permit a copy of this authorization to be used in place of the original. I have read and understand this agreement.

Signature______

Date______

(If you are a parent, or otherwise acting on behalf of the client, state your relationship______)

Secondary Insurance: _____ If you have secondary insurance, complete the following section):

Insurance Co. Name______

Insurance Co. Policy Number______

Insurance Group, Payor, or Plan Number (or name) ______

Insurance Company’s Benefits Phone Number______

Insurance Co. Address (if on your card) ______

Client’s relationship to Insured: ______Self ______Spouse ______Child ______Other

Signature On File & Authorization of Benefits Statement I am the client or a person responsible for the client. I authorize the use of this form on all my insurance submissions for services from this practitioner, Qubenic Yancey, LCPC. I authorize the release of medical or other information to my insurance company. I understand that I am responsible for my bill. I authorize my therapist to act as my agent in helping me obtain payment from my insurance companies. I authorize payment of medical benefits directly to my therapist. I permit a copy of this authorization to be used in place of the original. I have read and understand this agreement.

Signature______Date______

(If you are a parent, or otherwise acting on behalf of the client, state your relationship ______)

Credit/Debit Card Payment Should I choose to provide a credit or debit) card account number, I agree to allow for all payments and insurance copayments, missed appointment and late cancellation fees, and miscellaneous fees for letters and records to be billed to my credit card. This card number will be kept on record and any unpaid balances will automatically be paid by this card without prior notification.

Card Name (circle one): VISA MASTERCARD

Name of Cardholder______Expiration Date ______

Account Number______3-Digit Security Code (on back of card) ______

Billing Address for Card: ______

I authorize my credit card to pay fees due to Qubenic Yancey, LCPC:

Signature______

Print Name______Date______

(Please note that credit card charges will appear on your credit card statement as paid to Qubenic Yancey, LCPC.)