New Client Form

Today’s Date:_______________
A close up of a logo

Description generated with high confidence

Client Name:_________________________________ Sex:______ Date of Birth:__________________

Address:_________________________________City:__________________ State: _____ ZIP: _______

Home/Cell Phone: (______)_____________ Partnership: Single Married Other

Name of Partner:______________________With whom may we leave a message?_________________

May we leave messages on your voicemail? Yes No Text? Yes No

E-mail:___________________________________ Emergency Contact:___________________________

Contact Phone: (______)____________________ Relationship to Contact:________________________

Employer/School:____________________________ Work Phone: (_______)______________________

Do you accept calls at work? Yes No

INSURANCE INFORMATION

Primary Insurance:___________________ ID#:_______________________ Group#:________________

Policyholder Name:________________________ DOB:____________SSN:_________________

Secondary Insurance:___________________ ID#:_____________________ Group#:________________

Policyholder Name:________________________ DOB:____________SSN:_________________

Employee Assistance Program (EAP) Company Name:_________________________________________

Authorization#:____________________________ # of sessions:__________________________

Tricare: DOD Benefits #:_________________________________________________________________

Sponsor’s Name:______________________________ Branch:___________________________

Sponsor’s DOB:_______________________ Sponsor’s SSN:______________________________

Would you like to keep a card on file for billing purposes? Yes No

Name on Card:______________________________ Card #:____________________________________

Exp. Date:_________________CVV:________________ ZIP Code:_______________________________

I understand that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. I have read all the information provided on the office policies and have completed the above answers. I certify that this information is true and correct to the best of my knowledge. It is my understanding to notify BBH of any changes in my status and that BBH is not responsible for un-submitted insurance information 90 days past the initial visit.

Patient/Guardian Signature:________________________________________Date:_________________