New Patient

1. Please tell us about the person (patient) who will be seeing the counselor.

Name

First:

Middle:

Last:

Address

Street:

City:

State:

Zip:

Phone

Home:

Cell:

Work:

Personal Info

Birth Date:

E-Mail:

Gender:

Marital Status:

Employer or School:

City:

If Employed:

The patient's relationship to the owner of the insurance policy. Most often, the owner is the person who obtains the policy through employer, Medicaid, or Medicare:

2. If you will be using insurance:

Insurance Type:

Did you contact the insurance or EAP company before the first visit, to verify that the counselor is an accepted provider, and to obtain an authorization number, if needed?

Name of insurance company:

(The EAP company name is most often different from the health/medical company. If insured by Medicare and you also have a supplement, please show in the Secondary Insurance section farther down the page.)
If known, please fill in as much of the next section as you can:
Authorization number:

Number of visits:
From: To:
Subscriber or member number on health/medical insurance card:

Group number:

3. Please provide the following ONLY if the insurance policy owner (or the employee if EAP is used) is someone, such as parent or spouse, who is not the patient shown at the top of the page. (Just put "same" if address and home phone are same as patient)

Name

First:

Middle:

Last:

Address

Street:

City:

State:

Zip:

Phone

Home:

Cell:

Work:

Personal Info

Birth Date:

E-Mail:

Gender:

Employer

City

State

If Employed:

4. Please tell us how you learned about Families In Focus:


Other: ex: (Family or Friend (who?), Phone book (which one?), etc)

Secondary Insurance (if any)

Name of policy holder

Birth Date:

E-Mail:

Gender:

Employer

Insurance Company

Plan Name

Policy #

Group #

Consent for Treatment

You must check the following box to give permission for YOURSELF or YOUR DEPENDEND (under age 18) to be treated at Families in Focus.
I consent to treatment for my (self, son, daughter, etc..)

beginning on (today's date)

Check here if you accept these terms.

Agreement to Pay (when insurance coverage is used)

By checking this box, I understand that I am obligated to pay whatever the insurance does not pay within the guidelines of the therapist's contract with the insurance company.
In addition, I agree to pay the co-payment for my insurance, if required, and for any additional services rendered and not paid by the insurance company in the event that I neglect to advise Families in Focus in a timely manner concerning changes to my insurance coverage.

Check here if you accept these terms.

Cancellation Notification Policy

I agree to be thoughtful making my appointments, and understand that if I do not cancel at least 24 hours before the time of an appointment that I have made, I will pay a cancellation fee of $60.00. I understand that without sufficient notice, which includes leaving a message when the office is closed, the time that has been set aside for me (or my dependent) is lost to anyone else who may have needed or wanted an appointment.
Check here if you accept these terms.