<p> Qubenic Yancey, LCPC 1680 E. Gude Dr. Suite 114 Rockville, MD 20850 (443) 814-9769</p><p>Private Practice Counseling</p><p>PERSONAL INFORMATION PLEASE PRINT</p><p>Date ______</p><p>Name ______(Last) (First) (Middle)</p><p>Age______Date of Birth ______Social Security No.______</p><p>How did you hear about my service?______</p><p>Home Address______City______Zip______</p><p>Home Phone (_____) ______</p><p>May I contact you at home? By phone? Yes No By mail? Yes No</p><p>Marital Status______Years married______</p><p>Employer/School______</p><p>Work/School Address______</p><p>Work phone: (_____)______Mobile Phone (_____)______</p><p>May I contact you at work? By phone? Yes No By mail? Yes No</p><p>E-mail address (enter only if I may contact you by E-mail) ______</p><p>Emergency Contact - name & number:______</p><p>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:</p><p>Family Member’s Employer:______</p><p>Work Address______</p><p>Work Phone (______) ______</p><p>May we contact you at work? By phone? Yes No By Mail? Yes No</p><p>Page 1 of 4 Qubenic Yancey, LCPC 1680 E. Gude Dr. Suite 114 Rockville, MD 20850 (443) 814-9769</p><p>Private Practice Counseling</p><p>Other Household Members Name Age Relationship ______</p><p>______</p><p>______</p><p>Children Living Outside Home Name Age Name Age</p><p>______</p><p>Financially Responsible Party (complete this section if patient is a minor or is not responsible for payment):</p><p>Name: First______Last______MI______Social Security #:______Date of birth______Address______City______Zip______Employer:______Telephone: (Home)______Work______</p><p>Insurance Information: (Complete this section if you will be using any Health Insurance plan as part of your payment for services):</p><p>Insurance Co. Name______</p><p>Insurance Co. Policy Number______</p><p>Insurance Group, Payor, or Plan Number (or name) ______</p><p>Insurance Company’s Benefits Phone Number______</p><p>Insurance Co. Address (if on your card) ______</p><p>Client’s relationship to Insured: ______Self ______Spouse ______Child ______Other</p><p>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</p><p>Page 2 of 4 Qubenic Yancey, LCPC 1680 E. Gude Dr. Suite 114 Rockville, MD 20850 (443) 814-9769</p><p>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. </p><p>Signature______</p><p>Date______</p><p>(If you are a parent, or otherwise acting on behalf of the client, state your relationship______)</p><p>Secondary Insurance: _____ If you have secondary insurance, complete the following section):</p><p>Insurance Co. Name______</p><p>Insurance Co. Policy Number______</p><p>Insurance Group, Payor, or Plan Number (or name) ______</p><p>Insurance Company’s Benefits Phone Number______</p><p>Insurance Co. Address (if on your card) ______</p><p>Client’s relationship to Insured: ______Self ______Spouse ______Child ______Other</p><p>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. </p><p>Signature______Date______</p><p>(If you are a parent, or otherwise acting on behalf of the client, state your relationship ______)</p><p>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. </p><p>Card Name (circle one): VISA MASTERCARD</p><p>Page 3 of 4 Qubenic Yancey, LCPC 1680 E. Gude Dr. Suite 114 Rockville, MD 20850 (443) 814-9769</p><p>Private Practice Counseling</p><p>Name of Cardholder______Expiration Date ______</p><p>Account Number______3-Digit Security Code (on back of card) ______</p><p>Billing Address for Card: ______</p><p>I authorize my credit card to pay fees due to Qubenic Yancey, LCPC: </p><p>Signature______</p><p>Print Name______Date______</p><p>(Please note that credit card charges will appear on your credit card statement as paid to Qubenic Yancey, LCPC.)</p><p>Page 4 of 4</p>