Please Choose a Therapist:
NOTICE OF LIMITATION OF
INTERNET CONFIDENTIALITY: ALTHOUGH IT IS OUR
INTENTION TO MAINTAIN THE FULLEST CONFIDENTIALITY FOR ALL
COMMUNICATIONS, DUE TO OUR INABILITY TO CONTROL SOPHISTICATED INTERNET
INTRUDERS AND HACKERS WE CANNOT FULLY INSURE COMPLETE
CONFIDENTIALITY. WE THEREFORE ASK YOU TO CONSIDER THIS POSSIBILITY
IN ALL YOUR COMMUNICATIONS WITH US. WE WILL DO OUR BEST TO GUARD
ALL INFORMATION TO THE BEST OF OUR ABILITY. YOU MAY CHOOSE TO ONLY
PROVIDE MINIMAL INFORMATION AND LATER EXPAND AND CLARIFY THAT
INFORMATION ON A PERSONAL, FACE-TO-FACE LEVEL. IT IS OUR HOPE TO
ALLOW AN OPEN VEHICLE OF COMMUNICATION TO YOU WITH THIS UNDERSTANDING
AND SUBSEQUENT JUDGMENT ON YOUR PART. THANK YOU FOR YOUR UNDERSTANDING
AND PARTICIPATION.
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Name:
Date of Birth:
Male Female
Marital Status:
Address:
Home Phone Number:
Work Phone Number:
Can we leave a message?
At home? At
work? (Click what
applies).
Social Security Number:
*Primary Care Physician:
Location of PCP's Practice:
The below information can be found on your
insurance card. If you do not have insurance simply type self pay for
your insurance company's name and skip to the bottom.
Insurance Information
*Insurance Company's Name:
*Mental Health Benifits Phone Number:
*Subscriber Name:
*ID Number:
*Relationship to Patient:
*DOB:
*Social Security Number:
*Employer:
Briefly discribe the reason you are seeking
counseling.
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