Patient Registration

• Your answers are for our records only and will be kept confidential.
• Do not use the browser's back button.
• At the bottom of this form you will be asked to send us this information by clicking on the "Submit" button. Otherwise the information will not be saved.

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First Name:

Middle Initial:

Last Name:

Sex: Male Female

Date Of Birth:

Minor: Yes No

Social Security Number:   

 

If you are a minor please fill out the following Parent/Guardian information:

First Name:

Last Name:

Emergency Contact Number:

 

Patient Contact Information:

Street Address Line 1:

Street Address Line 2:

City:

State/Province:

Zip/Postal Code:

Home Phone:

Work Phone:

Cell Phone (Optional):

Fax:

Email:

If I cannot reach you do I have your permission to leave a message: Yes No

Are you employed? Yes No

Do you have a disability? Yes No

Are you a student? Yes No

If so.. Full-Time Part-Time

Insurance Information: Most insurance companies cover mental health services. However, sometimes the mental health services are contracted out to a different company. If this is the case, usually there is another phone number listed on your insurance card that specifically says "for mental/behavioral self services." Please verify that the information you provide below is the insurance company that pays for mental health services. If you are unsure of any insurance information, leave it blank. It will be verified at your appointment. Bring your insurance card or a copy of your insurance card (front and back) to your first appointment. If you do not wish to use an insurance company do not enter any information.

Primary Insurance Company:

Plan/Program Name:

Group Number:

Initial Authorization Number:

Claims Address Line 1:

Claims Address Line 2:

City:

State/Province:

Zip/Postal Code:

Phone:

 

Secondary Insurance Company:

Plan/Program Name:

Group Number:

Initial Authorization Number:

Claims Address Line 1:

Claims Address Line 2:

City:

State/Province:

Zip/Postal Code:

Phone:

 

Policy Holder's Information:

Name:

ID Number:

Date of Birth:

Relationship to Patient:

Street Address Line 1:

Street Address Line 2:

City:

State/Province:

Zip/Postal Code:

Name of Employer:

 

 

Important! Please Read!

RELEASE OF INSURANCE INFORMATION:  “I authorize the release of my Private Health Information  (which may include symptoms, diagnosis, dates of service, type of service provided) necessary to process my insurance claims and for management of services to the insurance company(s) listed above. I also authorize payment of mental health benefits directly to Teri Key, Ph.D.  I understand that I have the right to revoke or modify this authorization, in writing, at any time by sending written notification of that revocation or modification to Dr. Key’s office address.  However, my revocation or modification will not be effective until she receives it.” 

If you would like to use your medical insurance for treatment, please fill in today's date and confirm the information you have entered by pressing the "Submit" button. You will also be asked to sign a printed copy at the office. 

Authorization Date: