Full Name:

DOB:

Phone No:

Email Address:

Physical Address:

Insurance Carrier:

ID #

Group #

Mental Health Phone No:

Are the mental health benefits administered by a 3rd party company?

Are there any additional logos on the Id card from other companies other than the medical insurance company?

Please provide a front & back of your insurance card & driver’s license (25MB Limit).

Is there a phone number to call that other party?

Phone #

EAP?

EAP payer

Referral #

Credit Card to keep on File (It is required)

(we charge $100 for an intake to make sure the appt is kept)

Ex date:

Code:

We will email you the paperwork as well separately.

Thanks!

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