Client Information Form

Client Information Form

Please fill in the form below
Name

First NameMiddle NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
Sex
Marital Status
Social Security Number
SSN
Medicaid Number
Legal Guardian

First NameLast Name
Legal Guardian Contact

Area CodePhone Number
Legal Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician

First NameLast Name
Primary Care Physician Contact

Area CodePhone Number
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number:

Area CodePhone Number
Employer/School
Current Medical Conditions
Are you taking any medications currently?

YesNo
If yes, please list it here
Imbursement Information
Primary Insurance
Primary Enrollee Name

First NameLast Name
Enrollee #
Primary DOB

MonthDayYear
Date
Group #
Co-Pay Amount
Available Sessions Authorized
Secondary Insurance
Phone Number

Area CodePhone Number
Enrollee Name

First NameLast Name
Enrollee #
Group #
Co-Pay Amount
Available Sessions Authorized
*Counseling service fees are at $125.00 a session. Private fee for services of a counseling sessions will be at a rate of $80.00 per session. Office Hours: Mon.-Fri. 9am-5pm
Private Fee:

YesNo
Signature

Clear
Signature of Person Responsible for Payment of Services
Date

MonthDayYear
Date
Cheri McCormack Counseling Services, LLC

Cheri McCormack, M.Ed., LCPC
2005 Ironwood Parkway, Suite 210, Cd’A, ID 83814
Phone: (208) 661-1495 Fax: (208) 545 5222
Should be Empty:

Client Information Form

Imbursement Information

Cheri McCormack Counseling Services, LLC