New Patient Request Form
FAMILY THERAPY CLINIC OF LOUISIANA

***Due to continued caution for COVID-19, we are only conducting remote services (Video/Phone) at this time - Thank you for your understanding***
Your Name *
Relationship to Patient *
Patient Name (if different than self)
Patient DOB *
MM
/
DD
/
YYYY
Patient Gender *
Contact Phone Number *
Contact Email *
Emergency Contact Name *
Emergency Contact Phone Number *
Name of Insurance *
Insurance Member ID/Policy Number *
Primary Care Physician *
Who referred you or how did you hear about our clinic? *
Reason for Treatment *
***Please give as much detail as possible to determine best match with our therapists. Failure to do so WILL SLOW DOWN the intake process***
Preferred Provider *
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