Demographic Form

Address *

May Dr. Grant and his associates send a letter to your home address? *
Cell Phone Number *

Area Code Phone Number
May Dr. Grant and his associates contact you at this number? Leave a VM and/or text? *
Email *
example@example.com
May Dr. Grant and his associates contact you at this email? *
May Dr. Grant add your email to his blog, All Things Psychology? *
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *

Area Code Phone Number

Emergency Contact Address *

To submit insurance claims on your behalf, please complete below:
Name of Insured

First Name Last Name
Member ID
Insurance Carrier's Name
e.g., Anthem, Cigna
Provider Services Number

Area Code Phone Number
Insured's Date of Birth (if your parent is the holder of the insurance then this is your parent's DOB)

Month Day Year
Date Date Picker Icon
I authorize the release of treatment data, including drug and alcohol information, if required by my insurance. I also authorize all behavioral health benefits payable under my insurance policy to Matthew G. Grant, Psy.D., HSPP-dba-NorthStar Psychological + Consultation Services, LLC so that they may be applied to my account. The remainder left unpaid is my responsibility unless otherwise stated. Even if you're using your EAP benefits, please complete the insurance information section above in its entirety.
Signature *

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Initials *
Date You Signed the Form *

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DEMOGRAPHIC FORM