Last Name First M.I. Social Security # ______

PATIENT INFORMATION Child Form

Name: ______Birthdate: ______Last Name First M.I. Social Security # ______Home Telephone: ______Address: ______Work Phone: ______Cell Phone: ______

Father’s Name: ______Mother’s Name: ______Father’s Birthdate: ______Mother’s Birthdate: ______Father’s Social Security # ______Mother’s Social Security # ______Father’s Employer’s Name and Address: Mother’s Employer’s Name and Address: ______

Names and Ages of siblings: Family Physician: ______List below any medications your child is If separated or divorced please provide a currently taking: copy of your decree and indicate custodial ______arrangement: Joint Custody ______Custodial/Mother Custodial/Father Non-Custodial parent’s address: Primary Insurance:

______Insurance Company: ______Policy Holder: ______Non-Custodial Parent’s Member I.D.: ______Date of Birth: ______Group #: ______

Has your child seen another mental health Secondary Insurance: provider? Yes No Insurance Company: ______If yes, please list name and contact Policy Holder: ______information: ______Member I.D.: ______Group #: ______

Having insurance does not guarantee coverage. Some specific services and/or diagnoses may not be covered by your policy. It is your responsibility to contact your insurance company regarding your eligibility and benefit coverage. Your signature acknowledges that you are responsible for your bill. Signature: ______Date: ______