Please fill both pages of this form, as it will be used for billing with your insurance company and notifications. 
* - Indicates mandatory information you need to provide. 
PATIENT INFORMATION:	
*Last Name:                                                       *First Name :                                                    Middle Init:   	
*Patient Date Of Birth (MM/DD/YY):                                                                 Sex:  M     F    	
*Street Address:                      	
*City:                                               *State:                              *Zip:                         *Phone:  (     )  	
*Patient relationship to Insured:   SELF    Spouse    Child    Other 	
INSURED’S INFORMATION. Enter “SAME” in this section, if Patient is the same person as a main Insured person.	
* INSURED’S  ID# :                                                                             SSN: 
We always recommend providing SSN together with ID# due to the fact that some insurers still utilizing it.	
*Policy Group:                                                    Employer Name:  	
*Insurance Plan Name (*Mental Health Provider):  
*Address for Mental Health Claims Submission, P.O. Box/Street Address:
*City:                                               *State:                              *Zip:                         	
Is there another Health Benefits Plan:          Yes                NO          If Yes, provide information on reverse side 	
*Insured Last Name:                                                    *First Name:                                                Middle Initial:    	
*Date Of Birth (MM/DD/YY) :                                                                        Sex:  M     F    	
*Street Address:  	
*City:                                                *State:                          *Zip:                         *Phone:  (     )  	

Acknowledgment FORM:
I authorize use of' this form on all my insurance submissions and the release of information to my Insurance company. 
I understand that I am responsible for the full amount of my bill for services provided.
I authorize direct payment to my service provider and hereby permit a copy of this form to be used in place of an original.
In the event that your account goes to collection, there will be a 20% collection fee added to your balance. 
There is a 24-hour cancellation policy. Cancellations with less than 24 hours notice will incur a charge of $60.00, which will be billed to you, as it is not billable to insurance. 
Office Policy requires 72 hours notice for prescription refills.
*Patient Signature:                                                                           *Date:	

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. 
*Patient Signature:                                                                            *Date:	

Please update your contact information that will be used for appointment notifications/confirmations.

Email address:   

Primary Contact Phone:                                              

Phone type (please circle one):      Home          Office           Land Line              Cellular

Secondary contact Phone:           
                        
Phone type (please circle one):      Home          Office           Land Line              Cellular

Can we send a Text SMS message for appointment reminder and confirmation to your cellular phone?
                                                 
                                                                                                     Yes                NO          

What company is your cellular provider? (please circle one):

    AT&T              VERIZON        T-MOBIL           SPRINT       Metro PCS          Other (please specify):

What is a preferred method to confirm your appointment? (please circle one)

                 EMAIL                 Text SMS Message                     PHONE CALL