New Patient Questionnaire Date: _______________ Practitioner Requested: ________________________________
Patient’s Name(s):
____________________________________ DOB(s): ____________ Parents’ Names(if a child or adolescent): _________________________________________________________
Phone Number(s): Cell: ______________________ Home:______________
Brief Information about your situation and type of therapy you are interested in________________________________________________________________________ ________________________________________________________________________
Will you be using
insurance: Yes____ No_____
nsurance: ______________________________________________________________
Insurance Information Insured’s Relationship
to Patient: ( ) Spouse ( ) Parent ( ) Self ( ) Other: ____________ Name of Insured: __________________________________
DOB: _________________ Address: ________________________________________________________________ City: _________________________________
State: ________ ZIP: ________________
Employer: _______________________________ Insured’s SSN: __________________ Occupation/Title: __________________________
Work Phone: ___________________
Insurance Company/Plan: __________________________________________________ Insurance Phone Number: __________________________________________________
Insurance Claims Address: _________________________________________________ City: __________________________
State: ___________ ZIP: ____________________
Policy #: _____________________________________ Group #: ___________________