DEMOGRAPHICS
PATIENT INFORMATION:
NAME____________________________AGE______DOB____________________
ADDRESS_________________________________________ZIP_________________________
HOME PHONE________________________CELL________________________DL#________________
SSN______________________OCCUPATION______________________EMPLOYER_________________
MARRIED______DIVORCED______SINGLE______CULTURE OF ORIGIN________________________
PCP______________________PERMISSION TO CONTACT?____YES____NO
PSYCHIATRIST_________________________PERMISSION TO CONTACT?_____YES____NO
DISABILITIES___________________________HEARING OR VISION IMPAIRMENT_________________
YEARS OF EDUCATION_____________________________
__________________________________________________________________________________________IINSURANCE INFORMATION:
PRIMARY CARRIER____________________________PHONE #______________________________
ADDRESS____________________________________________________________________________
INSURED'S ID #______________________________GROUP #________________________________
INSURED'S SSN____________________________DEPENDENT'S SSN________________________
FIRST APPOINTMENT DATE___________________________
DEDUCTIBLE______________COPAY______________# OF SESSIONS____CERT#_____________
I hereby authorize payment directly to Paul Boone, LPC, LMFT, LCDC for services shown on claims sent to the insurance company and allow release to the insurance company for information requested by the insurance company and that regardless of assigned benefits, I am fully responsible for the full charge for services rendered and that fees are due at the time of service.
Signature____________________________Date_________________________