Intake Registration Form
Required to create your chart and schedule your first appointment. Please call our office at (843) 894-0000 if you have any questions or concerns while completing this form.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Last 4 digits of your SS#
*
Sex
*
Male
Female
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Insurance Company
*
Not using insurance? Type in "self pay"
Insurance ID#
*
Upload your Insurance Card
Upload your Driver's License / State I.D.
Upload your Credit / Debit Card (If your insurance covers 100%, you won't be charged! However, this is kept on file to book the appointment in our system.)
3 digit CVV on back of card:
blanks
Billing zip code:
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Responsible Party / Spouse Information
Only required if your insurance card is in another person's name.
Policy Holder Name
First Name
Last Name
Relationship to Patient (SKIP IF NOT APPLICABLE)
Spouse
Parent
Other
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Signature
l certify that the information above is accurate and complete. I agree to be contacted by Oceanic Counseling Group LLC / SimpleCounselor to complete the intake registration process and book an appointment.
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Submit
Should be Empty: