Resources

Please complete this form ONLY after you have an appointment scheduled with one of our therapists.

New Client Insurance Information

Client

First Name:  
Middle Initial:  
Last Name:  
Birthdate:  
Email:  
Phone:  
Address:  
City:  
State:
Zip Code:  

Financially Responsible Party

First Name:  
Middle Initial:  
Last Name:  
Birthdate:  
Phone:  
Address same as client?
Address:  
City:  
State:
Zip Code:  

Insured (person who has the policy through his/her employer)

Address same as client? if so, no need to complete this section
First Name:  
Middle Initial:  
Last Name:  
Birthdate:  
Phone:  
Address:  
City:  
State:
Zip Code:  
Employer:   
Insurance Co:  
Insurance Phone For Providers:  
Policy #:  
Group #:  
Claim Address:  
Claim City:  
Claim State:
Claim Zip: