Client Name______________________________Birthdate_______________Sex____________________
Address_______________________________________City___________________State____Zip______
Home Phone_________________________Business_____________________Cell___________________
May we leave a message on these phones_____________________________________________________
Emergency Contact______________________________________________________________________
Employer_____________________________________Referred by_______________________________
Marital Status ________________________Spouse’s Name and Birthdate__________________________
Children’s Names and Birthdates___________________________________________________________
_____________________________________________________________________________________
Responsible party name, address and telephone_______________________________________________
_____________________________________________________________________________________
If under 18
Brothers and Sisters names and birthdates____________________________________________________
_____________________________________________________________________________________
Mother/Guardian_____________________________Address____________________________________
Date of birth_____________Home Phone__________________________Work Phone________________
Parent/Guardian_____________________________Address_____________________________________
Date of birth_____________Home Phone___________________________Work phone_______________
Insurance Information
Insurance Company_____________________________________________________________________
Card holders name____________________________Relationship to you: Self__Spouse__Dependent__
Address___________________________________________City______________State___Zip________
Group Number_____________ID number______________________Phone________________________
Secondary Insurance____________________________________________________________________
Card Holders Name__________________________Relationship to you: Self--Spouse__Dependent_____
Address___________________________________________City______________State___Zip_________
Group Number_____________ID Number______________________Phone________________________
Authorization: I authorize the Center for Interpersonal Development (CID), and any employee working under the direction of the therapist, to provide care for me, or to this patient for which I am the legal guardian. I also authorize CID to furnish information to the identified insurance carrier(s) for prior authorization, pre-certification of payment of health care services. The information may include claims copies of medical information, faxes and phone calls concerning care provided or proposed. I shall assign all payments for these services to CID. I understand that I am responsible for all co-payments, amounts applied to deductibles and other amounts that may be deemed my responsibility by the insurance plan, as required by my contract with my insurance plan and state regulation. I further understand that my contract with my health care insurance entity may or may not cover some services. It is my responsibility to obtain information from my health plan about service coverage. If I seek care outside of the contract, I am aware that I may be responsible for all charges that are incurred.
Client/Guardian___________________________________Date_______________________________
