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_________________________