New Client Intake

New Client Intake
Client's Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Name *

First Name Last Name
Cell Phone

Area Code Phone Number
Home or Work Phone *

Area Code Phone Number
E-mail
Parent/Guardian

First Name Last Name
Parent/Guardian Cell Phone

Area Code Phone Number
Home or Work Phone

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

First Name Last Name
Primary Care Physician Phone *

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

Area Code Phone Number
Member ID Number *
Group ID Number
Policy Holder's Name

First Name Last Name
Policy Holder's Date of Birth

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

Yes No
Secondary Health Insurance Carrier
Secondary Health Insurance Phone

Area Code Phone Number
Member ID Number
Group ID Number
Policy Holder's Name

First Name Last Name
Policy Holder's Date of Birth

Month Day Year
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. *

Yes No
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