"*" indicates required fields Ephesians Professional Counseling REGISTRATION INFORMATION Therapist*Select TherapistBethesda - Leslie MarlerCollege Park - Dianne Fisher-GriffithCollege Park - Belita ProctorClient Information Please fill in this section with the Client's information. Name* First Middle Last Birthday* Month Day Year Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Number where client can be reached.Email*Email where client can be reached. SS#Client's Social Security Number. Client is:* Male Female Marriage Status*SingleMarriedDivorced / SeparatedWidowedSignificant OtherOtherStudent?* Yes No Briefly Describe symptons, illness or accident:*Date of onset of symptoms (MM/YY)*Employed?* Yes No Employer or Company NameEmployer's Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Occupation*Driver's License #Name of doctor or person who referred you and how you found usInsurance Information Please fill in this section with the Insurance Policy Holder's information if it is not the same as the client's.Is policy holder information the same as client?* Yes No Policy Holder's Name* First Middle Last DOB* Month Day Year Phone*Email*SS#Social Security NumberAddress* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Insurance Company*ID #*Group #Insurance Phone*Effective Date MM slash DD slash YYYY Relationship to Client*SelfSpouseParentOtherBy entering my initials below I understand that Insurance coverage is not a guarantee of benefits and that determination will be made at the time the claim is received. I also understand that I am responsible for the balance if the claim is denied and also for any co-insurance or annual deductible that is applicable. All payments are due at the time of service. I also understand that I am responsible for all appointments and I will be charged a fee of $65 unless I give 24 hours’ notice of cancellations. Late fees are due at the next appointment.Initials showing agreement to above statement*Date Initialed* MM slash DD slash YYYY Emergency Contact Information In case of an emergency please provide a person we can contact.Contact Name*Relationship to Client*Primary / Cell Phone*Secondary Phone (Work/Home)Assign and Release I authorize payment of Medical Benefits to this facility/provider. I authorize release of any medical information necessary to process the claim and/or I also request payment of government benefits either to myself or party who accepts assignment.Who is signing?* Client Parent/Guardian/Legal Authority Print the Name of Person Signing the Form:*I acknowledge that I am 18 years old or have legal authority to sign for the Client* Yes EmailThis field is for validation purposes and should be left unchanged.
