Please Complete:
The following questions are intended to provide Dr. Goldberg with information about your treatment interests. All information is strictly confidential.
Personal Information
Full Name *
Your answer
Date of Birth *
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E-Mail Address *
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Address *
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Address 2
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City *
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State *
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Zip Code *
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Daytime Phone *
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Evening Phone
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Marital Status *
Additional Information
How were you referred to Dr. Goldberg? *
Have you or any other immediate family member ever been seen by Dr. Goldberg? *
If yes to above, please indicate the patient's name:
Your answer
Have you used any mental health insurance benefits this calendar year? *
How many visits with a mental health clinician have you had this year?
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Are you currently seeing any other mental health provider? *
If yes to above, please provide the name(s) and telephone number of those clinicians:
Your answer
Have you ever been hospitalized for psychiatric reasons? *
If yes to above, when was the last hospitalization?
Your answer
Insurance Information
Do you plan to use a health plan to pay for these services? *
If so, what is the name of your current insurance provider?
What type of plan do you have?
Other Insurance Plan (Please Specify)
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Name of subscriber on insurance policy?
Your answer
What is your Plan Identification Number?
Please refer to the front of your insurance card for this information
Your answer
What is your Plan Suffix number?
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What is the telephone number for mental health benefits?
This number is generally available on the back of your insurance card
Your answer
How May We Help?
Please briefly describe the nature of the problem you are seeking services for: *
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What type of services are you seeking? Check all that apply: *
Required
Do I have permission to leave a general message on your answering machine? *
When would you be able to come for services on a regular basis? *
Please Provide Specific Day(s) and Time(s)
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