Name *
Name
Parent/Guardian Name
Parent/Guardian Name
Patient Date of Birth *
Patient Date of Birth
Parent/Guardian Date of Birth
Parent/Guardian Date of Birth
Home Address *
Home Address
Contact Phone *
Contact Phone
Insurance Information
Phone number for Providers (on the back of card) *
Phone number for Providers (on the back of card)
Insured Date of Birth
Insured Date of Birth
Signature *
Signature
If it is necessary to cancel your scheduled appointment we require that you call by 10 a.m. one (1) working day in advance. If you are unable to cancel by this time you will be charged a $25 cancellation fee. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely care. I hereby authorize the release of any medical information necessary to process my insurance claims. I permit a copy of this authorization to be used in place of the original. By signing this form, I am authorizing medical/psychological treatment by LeafCrest Counseling. I also authorize payments of medical benefits directly to LeafCrest Counseling for services received in this office, if assigned. I understand that I am financially responsible for all fees incurred for services rendered by Leafcrest Counseling, which are not paid by my insurance.