New Returing Client Registration

Client and/or Primary Insured Registration

Re-type email

Client State: *

To better serve you, fill out all fields if you are a new or returning client and are requesting services from our office. All clients who receive an insurance plan from a parent or spouse (partner) are required to also provide the primary insured information in the bottom portions of this form. This information is required to check your benefits and for insurance billing purposes. Primary insured is the person who is providing the insurance through employment or directly.

Thank You For Your Registration.

PRIMARY Insured Last Name:

PRIMARY Insured BD :

Client First Name: *

Client Birth Date *

Your Copay:

Client Phone or guardian: *

Minor's Parent Name:

Insurance Deductible Amount:

Client Address: *

PRIMARY City:

Client Last Name *

Primary Insurance ID# :

Client City: *

PRIMARY Zip:

Gender *

Insurance Co. Name:

Authorization No. :

PRIMARY Insured First Name:

PRIMARY State:

PRIMARY Address:

Family

Behavioral

Health

Insurance Co. Phone:

Employer Providing Ins:

PRIMARY Cell :

Client Zip Code: *

559-432-1088

Statewide Telehealth

HIPPA Compliant

Video Conferencing

Emergency Contact Phone:

Comments

Insurance Card ID #: