Client Face Sheet

Name*

First Last

Date Of Birth*

Home Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number*

Work Phone

Email Address*

Cell Phone

Occupation

Employer

In Case Of Emergency Notify:*

Relationship*

Emergency Phone Number*

Hospital Preferred

Referred By:

Reason For Visit*

Insurance Company

Name Of Insured/ Relationship

Provider Inquiry Phone Number

Insurance Group #

Insurance Plan Code

Paying Out Of Pocket?*

Yes
No

Consent*

I UNDERSTAND THAT I WILL BE RECEIVING ONLY ACCEPTED AND TRADITIONAL PSYCHOTHERAPY, ACCORDING TO PROFESSIONAL LICENSURE REQUIREMENTS OF THE STATE OF MICHIGAN, AND THAT I AM RESPONSIBLE FOR THE FEE AT THE TIME OF THE OFFICE VISIT. MY INSURANCE COMPANY MAY BE BILLED AS A COURTESY, IF MY INSURANCE COMPANY AGREES TO REIMBURSE THE THERAPIST. PLEASE BE AWARE THAT ALL FINANCIAL OBLIGATIONS MUST BE FULFILLED PRIOR TO ANY RECORD REQUESTS BEING RELEASED.

Signature