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New Patient Registration Form
Patient Information
Name
(Required)
First
Last
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
(Required)
Cell Phone
(Required)
Marital Status
Single
Married
Children & Ages
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Relationship to Patient
Preferred clinician to work with?
(Required)
If you have a preferred clinician you’d like to work with please type their name in this field. If not type N/A.
Medical Information
Primary Care Physician
(Required)
Medications
Insurance Information
Primary Carrier
(Required)
Subscriber Name
(Required)
First
Last
Subscriber Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
DOB
(Required)
MM slash DD slash YYYY
Subscriber ID #
(Required)
Group ID #
(Required)
Secondary Carrier
Subscriber ID #
Group #
Subscriber Name
First
Last
PLEASE READ CAREFULLY
(Required)
I AGREE
I hereby authorize the release of information necessary for third-party claim submission and/or payment services. I authorize payment of third party benefits by Jeffrey Williams, LMSW for therapy services provided. I understand that I am responsible to pay Jeffrey Williams, LMSW for all services rendered for all sessions rendered. Additionally, there is a fee for any no show or late cancellation, less than 24 hours prior to your scheduled appointment.
