<p>10061 Talbert Avenue, Suite 200, Fountain Valley, CA 92708. Phone: 714-965-3622/ Fax: 714-963-4703</p><p>NEW CLIENT INFORMATION</p><p>PATIENT NAME:______TODAY’S DATE:______</p><p>DATE OF BIRTH:______SEX:______MARITAL STATUS:______</p><p>HOME ADDRESS:______CITY/STATE/ZIP:______</p><p>HOME PHONE:______BUSINESS PHONE:______</p><p>CELL PHONE:______PATIENT SS#:______</p><p>STUDENT STATUS: _____Non Student _____Full Time _____Part Time _____Unknown</p><p>**************************************************************************</p><p>Person financially responsible for payment of services and/or subscriber of the primary insurance plan:</p><p>SUBSCRIBER:______SS#:______</p><p>HOME ADDRESS:______CITY/STATE/ZIP:______</p><p>HOME PHONE:______BUSINESS PHONE:______</p><p>OCCUPATION/TITLE:______EMPLOYED BY:______</p><p>SUBSCRIBER DATE OF BIRTH:______POLICY ID NUMBER:______</p><p>INSURANCE COMPANY:______PLAN NAME/GROUP #:______</p><p>Subscriber relationship to patient: _____Self _____Parent _____Spouse _____Dependent _____Other</p><p>Employment: _____Full Time _____Part Time _____Not Employed _____Retired _____Other</p><p>Below For Office Use Only:</p><p>Provider Name:______Co Pay:______</p><p>Services: _____Individual _____Family _____Testing _____Group _____Other</p><p>Diagnosis: Code:______Description:______</p><p>Diagnosis: Code:______Description:______</p><p>THERAPISTS: PLEASE ATTACH COPY OF INSURANCE CARD (front & back) TO THIS FORM.</p>