Karen Griswold, LPC
Client Information and Insurance Form Today’s Date_________________
Client’s Name________________________________Date of Birth___________
Street Address__________________________________________Age_______
City_____________________Zip ___________Home Phone_______________
Cell phone___________________ Email ______________________________
Social Security #_______________Single ___ Married___ Domestic Partner___
Occupation______________________________________Gender___________
Employer______________________________Work Phone________________
Education level______________ Referred by___________________________
Emergency Contact_________________________Phone__________________
May we leave messages for you at home? Yes No At work? Yes No
Partner Information (if being seen as a couple)
Name______________________________________Date of Birth___________
Occupation__________________________________________Age_________
Employer_____________________________Work Phone_________________
Insurance Information:
Name of Insured______________________________Date of Birth___________
Address of Insured_________________________________________________
Relationship of Client to Insured______________________________________
Employer of Insured________________________________________________
Insurance Company________________________________________________
Address of Insurance Company_______________________________________
City, State, Zip____________________________________________________
Insurance phone number for providers_________________________________
Insurance Identification #_____________________Group #________________
Amount of deductible_________Has it been met for this calendar year?_______
Secondary Insurance Information:
Name of Insured_____________________________Date of Birth____________
Address of Insured_________________________________________________
Relationship of Client to Insured______________________________________
Employer of Insured________________________________________________
Insurance Company________________________________________________
Address of Insurance Company_______________________________________
City, State, Zip____________________________________________________
Insurance phone number for providers_________________________________
Insurance Identification #_____________________Group #________________
Patient or Authorized Person’s Signature: I authorize the release of any medical or other information necessary to process a claim and collect monies due from and through insurance companies and other agencies as needed. I also request payment of government benefits either to myself or to the party who accepts assignment.
I authorize payment of medical benefits to the provider of services.
_______________________________________________Date_____________
(Signature)