ESE Mental Health Registration Form

Teletherapy Patient Information Form
Please select the statement that best describes the patient.*

Is a student.Is over 18.
ESE Mental Health Location
Associated School*
Florida Schools
Georgia Schools
Foothills Regional High School Campus
School name
Reffered by or school point of contact.
* Please list full Legal Name.
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Sex:*
Patient Age
Reason for Teletherapy Visit*

DepressionAnxietyPost Traumatic StressLoss in FamilyPanic AttacksPsychiatric DisorderDivorceLow Self EsteemOther
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Cell Phone
Patient Email Address:
example@example.com
Parent/Guardian Cell:
Parent/Guardian Email
example@example.com
* If your insurance requires a deductible to be met or you choose Self Pay, you shall be responsible for paying the full amount of each session before each is scheduled. $85 per Session.

PAY HERE!!!
Payment Option

InsuranceSelf Pay
Payment Option for Jefferson County Florida*

InsurancePatient does not have insurance and would like to apply for indigent care.
I affirm that the patient does not have health insurance and has gone through the eligibility and qualification process for Medicaid.

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Insurance Company Name
Member's Name on Insurance Card
Member ID
Member Date of Birth
Group #:
Parent/Guardian Name (if patient is under age 18)*
Member Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a copy of the FRONT of your insurance card

FRONT OF INSURANCE CARD
Cancelof
Upload a copy of the BACK of your insurance card*

BACK OF INSURANCE CARD
Cancelof
Responsible Party Information
Parent/Guardian/Patient(if over 18):
Phone:*
Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Privacy Policy*
Privacy Policy Spanish
Financial Policy*
Financial Policy Spanish
Telemental Health Informed Consent.*
Telemental Health Informed Consent Spanish.
Signature
Should be Empty:

Teletherapy Patient Information Form

ESE Mental Health Location

Responsible Party Information