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Name

Date of Birth

Sex

Phone

Email

Will You Be Using Health Insurance?

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Will you be Paying Cash?

Yes

No

Insurance Provider

Plan Name

Member ID

Group ID

Address

Adddress, City, State, ZipCode

Are you the Policy Holder?

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First Name

Policy Holder First Name

Last Name

Policy Holder Last Name

Date of Birth

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Back of Insurance Card

What days work best for your Appointment?

Monday
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Wednesday
Thursday
Friday

What time of day works best for your Appointment?

12:00PM-03:00PM
03:00PM-05:00PM
05:00PM-07:00PM

Reason for Visit?

ADD/ADHD
Addiction/Substance Abuse
Anxiety
Bipolar Disorder
Depression
Panic Disorder
Prescription/Refill
Post-traumatic stress disorder (PTSD)
Stress
Trauma
Other

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