Client InformationClient Name First Address City Leesburg State Zip Code Cell/Home PhoneAlternate PhoneMarital Status DOB SS# Gender Race/Ethnicity Referral Source PhonePrimary Care Physician PhonePsychiatrist PhoneParent/Guardian (if applicable) Patient/Guardian Employer Client’s Primary Insurance Policy # Policy Holder Name First DOB Secondary Insurance Policy # Reason for Seeking Services Appointment 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 CAPTCHA
