Christian Therapy Services
ALL INFORMATION IS TREATED WITH STRICTEST CONFIDENCE
P L E A S E P R I N T L E G I B L Y
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Patient ________________________________________ _______ _______________________________
First Name MI Last Name
___________________________________________________ ______________________________ _____ ________
Address City State Zip
E-mail Address ____________________________________ John Thurman ONLY--Monthly Newsletter? Y ___ N ___
Phone Numbers: Indicate order to be contacted (1, 2, 3 or 4). List area code for long distance calls.
_____ Cell (______) _____________________ _____ Home (______) _______________________
_____ Work (______) _____________________ _____ Other (______) _______________________
__________________________________________ ____________________________ _______ _______________
Social Security Number Birth Date Age Sex: Male/Female
Martial Status: _____ Single _____ Married _____ Divorced _____ Separated _____ Widowed
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Responsible
Party ________________________________________ _______ ________________________________
(if other than Patient) First Name MI Last Name
_______________________________________________ ______________________________ _____ _________
Address City State Zip
E-mail Address _______________________________________ Relationship to Patient_______________________
Phone Numbers: Indicate order to be contacted (1, 2, 3 or 4). List area code for long distance calls.
_____ Cell (______) _____________________ _____ Home (______) ______________________
_____ Work ______) _____________________ _____ Other (______) ______________________
____________________________________ __________________________________________ _______________
Social Security Number Birth Date Sex: Male/Female
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Card Type
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Card Number
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Expiration Date
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__VISA __Mastercard
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Insurance Information
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Primary
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Secondary
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Company Name
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Insured ID #
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Insured’s Policy Group #
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Authorization #
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Co-payment Amount
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Insurance Consent Disclaimer: If you choose to use your insurance benefits for Mental Health Services, we will use a
medical code on your insurance form that states that you have been treated for a mental illness. This code will be with
your medical records for the rest of your life. If you choose to pay for the services yourself, the only record of the visit
will stay at this office.
Patient/Responsible Party Signature Authorizes: payment of outstanding balances for therapy session(s) and related fee(s) by cash or credit card and processing of Insurance Claims.
_____________________________________________________________________ Signature Date
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