The Trahan Therapy Center Appointment Form
Please answer each question completely. Without complete information it might cause us to be unable to bill your insurance company or even be to verify your coverage. We do not share your information with any third parties.
Email address *
First/Last name of primary insured/client *
Date of birth *
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Social Security Number *
Address (Street #, name, apartment #, city, state and zip code) *
Phone number of insured/client
Occupation of primary client *
Insurance ID Number(include all alphabet and numbers) *
Provider phone # on the back of your insurance card
Name of second party involved (mate/spouse)
Date of birth (2nd party involved)
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/
DD
/
YYYY
Phone # of 2nd party involved *
Email of second party involved
Second party Insurance type, Insurance ID Number and phone number on the back of insurance card
Current psychiatrist that you allow us to contact on your behalf if needed
Current psychiatrist address that you allow us to contact on your behalf if needed
Current psychiatrist phone number that you allow us to contact on your behalf
Purpose of visit *
Required
How old is the person being seen?
Have you seen any of the following? *
Required
If you have seen one of the above, how long ago was it? *
Have you ever been diagnosed with any of the following? *
Required
Choose all days that you can be available to have therapy weekly? *
Required
Which would you be interested in? *
Required
Choose all times that work for you *
Required
List medications that you currently take, purpose for each and dosage(s) *
In case of an emergency, who should I contact for you, what is your relationship to them and what is their number?
Which insurance(s) do you have? *
Required
How did you find out about The Trahan Therapy Center? *
Would you be interested in any of the following? *
Required
A copy of your responses will be emailed to the address you provided.
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