Client InformationClient Name First AddressCityLeesburgStateZip CodeCell/Home PhoneAlternate PhoneMarital StatusDOBSS#GenderRace/EthnicityReferral SourcePhonePrimary Care PhysicianPhonePsychiatristPhoneParent/Guardian (if applicable)Patient/Guardian EmployerClient’s Primary InsurancePolicy #Policy Holder Name First DOBSecondary InsurancePolicy #Reason for Seeking ServicesAppointment RemindersPlease check the box with your preferred method to be notified of your appointment date & time (Only select one option) Reminders may be given up to 3 days in advance depending on the date of your appointmentEmail Reminder Email Reminder Email Phone Call Phone Call PhoneAre Voicemails with Appt. Time & Date OK? Yes No No Reminder No Reminder Email and text are not secure forms of communication. Please do not email or text clinical information. I agree that appointment reminders are strictly a courtesy and understand missed appointments are my financial responsibility that will not be covered by my insurance. My signature below shows that I understand and agree with these terms. Client/Guardian Signature/PrintRelationship to Client
