CLIENT INTAKE for Christie Applewhite, LCSW

NameClick here to enter text.

Social Security Number Click here to enter text.

Home Address	Click here to enter text.

City Click here to enter text. StateClick here to enter text. ZipClick here to enter text.

Primary PhoneClick here to enter text.	Alt. PhoneClick here to enter text.

ok to leave msg? yes☐no☐

Email address that can be used to confirm appts.Click here to enter text.

Sex Click here to enter text. AgeClick here to enter text. Date of BirthClick here to enter text.

Employer/school nameClick here to enter text.

Name of Parent/ Guardian (if client is a minor)Click here to enter text.

Emergency ContactClick here to enter text.	PhoneClick here to enter text.

INSURANCE INFORMATION

Name of InsuredClick here to enter text.	Relationship to ClientClick here to enter text.

Home Address and Phone Click here to enter text.

Employer Address and Phone Click here to enter text.

Insured SS#Click here to enter text.	Insured’s Primary Insurance CompanyClick here to enter text.

Policy or ID#Click here to enter text.	Click here to enter text.Group #

Phone number on card to call for mental health benefitsClick here to enter text.

OFFICE BILLING AND INSURANCE POLICY

I authorize use of this form on all of my insurance submissions.

I authorize the release of information to my insurance company.

I understand that I am fully responsible for the full amount of my bill for services provided.

I authorize direct payment to my service provider.

I hereby permit a copy of this to be used in place of an original.

It is your responsibility to pay any deductible amount, co-pay, co-insurance amount or any other balance not paid by your insurance company.

There will be a $25.00 service charge on all returned checks.

**THERE IS A 24-HOUR CANCELLATION POLICY WHICH REQUIRES THAT YOU CANCEL YOUR APPOINTMENT 24 HOURS IN ADVANCE TO AVOID BEING CHARGED THE FULL FEE FOR YOUR SESSION SINCE INSURANCE CANNOT BE BILLED FOR NO-SHOW APPOINTMENTS.

Payment is expected at the time services are rendered in the form of cash, credit/debit card, or check made payable to Christie Applewhite, LCSW.

SignatureClick here to enter text.	DateClick here to enter text.