Complete New Paperwork

Type of Services Sought
Please check all services you are interested in at this time
Individual Therapy/Counseling
Couples Therapy/Counseling
Family Therapy/Counseling
Psychological Testing/Assessment
Drug/Alcohol Evaluation
Child Custody Evaluation
Other Service

Demographic Information
Name of Patient:


Patient Address (Street, City, State, & Zip):


Patient Phone Number:


Patient Email Address:


Marital Status of Patient:


Date of Birth of Patient:


Employer of Patient (if applicable):


School Patient Currently Attending (if applicable):


Insurance & Financial Information
Name of person responsible for medical bills:


Name of Insurance Provider:


Insurance Provider Phone Number:


Member ID Number:


Group ID Number:


Name of policy holder/insured:


Date of birth of policy holder/insured:


Claims Address (find on back of your insurance card):


Emergency Contact
Name & phone for person we should contact in case of emergency:


Who referred you to us?:


If Patient is Under Age 18: Name, Address, & Phone of Mother:


If Patient is Under Age 18: Name, Address, & Phone of Father:


If Patient is Under Age 18: Please note who has legal custody of this child:



To schedule a free phone consultation or appointment, please email us or call (630)777-7113.