New Client Intake

New Client Intake
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Name*

First NameLast Name
Cell Phone

Area CodePhone Number
Home or Work Phone*

Area CodePhone Number
E-mail
Parent/Guardian

First NameLast Name
Parent/Guardian Cell Phone

Area CodePhone Number
Home or Work Phone

Area CodePhone Number
E-mail
Client's Primary Care Physician*

First NameLast Name
Primary Care Physician Phone*

Area CodePhone Number
Insurance Information
Health Insurance Carrier*
Health Insurance Phone

Area CodePhone Number
Member ID Number*
Group ID Number
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Do you have secondary insurance? (i.e. Medicaid, Katie Beckett, etc...)*

YesNo
Secondary Health Insurance Carrier
Secondary Health Insurance Phone

Area CodePhone Number
Member ID Number
Group ID Number
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
I authorize Capstone Speech Therapy, LLC to release records to the insurance company or other payors as requested in order to authorize therapy and facilitate claims payment. Additionally, failure to provide all information regarding insurance coverage will result in delays which will affect treatment.*

YesNo
Should be Empty: