Insurance Information Patient Intake Form

Therapist:

Patient Information:

Name:

Date of Birth: Male: Female:

Street Address: P.O. Box:

City: State: Zip:

Please Check Applicable: Single Married Employed Student

Policy Holder: (If not the Same as Above)

Name:

Date of Birth: Male: Female:

Relation: (Self, Spouse, Child)

Primary Insurance Company Information:

Insurance Company:

ID Number: Group Numbre (if applicable):

Insurance Co. Address:

City: State: Zip:

Insurance Co. Phone:

Secondary Insurance Company Information:

Secondary Insurance Company:

2nd Insurance Co. Address: P.O. Box:

City: State: Zip:

2nd Insurance Co. Phone:

Employer:

Employer:

Annual Deductible:

Co-Payment: Diagnosis: