ESE Mental Health Registration Form

Teletherapy Patient Information Form
Associated School*
School name
* Please list full Legal Name for Insurance Purposes
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Sex:*
Patient Age
Type of Patient*

StudentTeacher
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

Area CodePhone Number
Patient Email Address:
example@example.com
Parent/Guardian Cell:
Parent/Guardian Email
example@example.com
Insurance Information
* 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. $125 Initial Session. $95 Additional Session.

PAY HERE!!!
Payment Option*

InsuranceSelf Pay
Insurance Company Name
Member's Name on Insurance Card
Member ID
Member Date of Birth
Group #:
Relationship to Patient
Member Home Address

Street Address

Street Address Line 2

CityState / Province

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

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

Browse Files
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*
Financial Policy*
Telemental Health Informed Consent.*
Signature
Should be Empty:

Teletherapy Patient Information Form

Insurance Information

Responsible Party Information