Client Information
Please complete this form and submit it before your first visit. If you are not the Subscriber, please complete and submit an additional form for that person. Thanks, David Friedler, LMHC
Last Name *
Your answer
Middle Initial
Your answer
First Name *
Your answer
Street 1 *
Your answer
Street 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone 1
(refers to home phone)
Your answer
Phone 2
(refers to work phone number)
Your answer
Phone 3 *
(refers to cell phone number)
Your answer
Date of Birth *
Your answer
Sex *
(Male or Female)
Your answer
Contact Name *
(Emergency Contact Name)
Your answer
Contact Phone 1 *
(Emergency Contact Phone)
Your answer
Contact Phone 2 *
(Emergency Contact Cell Phone)
Your answer
Marital Status
Your answer
Employer
Your answer
Subscriber ID *
Your answer
Group No
Your answer
Plan Name *
Your answer
Insured Authorization *
(Yes or No)
Your answer
Deductible *
(No $ sign or 0)
Your answer
Copay *
(No $ sign or 0)
Your answer
SOF Date *
(Today's Date)
Your answer
Employment Status
(Employed/Student, Full-Time or Part-Time
Your answer
Email *
Your answer
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