Demographic Form

DEMOGRAPHIC FORM
Name

First NameMiddle InitialLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
May Dr. Grant and his associates send a letter to your home address?
Cell Phone Number

Area CodePhone 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 NameLast Name
Emergency Contact Phone

Area CodePhone Number
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To submit insurance claims on your behalf, please complete below:
Name of Insured

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

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Initials
Date You Signed the Form

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

DEMOGRAPHIC FORM