Please download and complete the following forms before your first session. If you have any question, please let your therapist know before being seen.

How to file a Complaint or Grievance Consent for Services Notice of Privacy (HIPPA)

CCA form - Medicaid Clients ONLY

Patient Information Form

First Name and Middle Initial

First Name

Last Name

Marital Status

Gender Identity

Race

Social Security Number

Date of Birth

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Care Physician

Referral Source

How did you hear about us?

Reason for visit

Pharmacy Name & Number

Allergies

Information on Child (if patient is a minor)

School

Grade

Teacher

Counselor

Special Education

Responsible Party Information

First and Middle Initial

First Name

Last Name

Social Security Number

Date of Birth

Employer

Work

(###)

###

####

Mobile

(###)

###

####

Insurance Information

Primary Insurance

BCBS, Cigna, Aetna, etc....

Subscriber ID#

Group #

Insured Name

Relationship to Patient

Secondary Insurance

BCBS, Cigna, Aetna, etc....

Subscriber ID#

Group #

Insured Name

Relationship to Patient

Emergency Contact Information

Emergency Contact

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship to Patient

Assigned & Release

Patient/Parent or Guardian Signature (if minor)

I hereby authorize payment of medical benefits to this Physician and/or Licensed therapist for all services rendered by them. I also authorize the release of any information necessary to process these insurance claims.

Date

Todays Date

YYYY