|
Peace of Mind, Inc. |
|
817 West Front Street P.O. Box 2088 Lillington, NC 27546-2088 Phone: (910) 814 - 2197 Fax: (910) 814 - 2167 |
|
|
|
|
|
|
|
____________________ Clinician ____________________ Record
CLIENT REGISTRATION – PEACE OF MIND, INC.
CLIENT’S LAST NAME ___________________________ FIRST NAME _____________________ INITIAL _________
ADDRESS _______________________________________________________CITY ________________________________
STATE _______ ZIP ________________ SEX ________ EMAIL ADDRESS_____________________________________
HOME PHONE __________________ WORK/CELL PHONE ___________________ DATE OF BIRTH______________
CLIENT’S SOCIAL SECURITY NUMBER _______________________________ MARITAL STATUS _______________
GUARANTOR INFORMATION (Please complete if client is a minor)
MOTHER’S NAME: ____________________________________________ SSN __________________________________
FATHER’S NAME: _____________________________________________ SSN _________________________________ ____________________________________________________
1. TRICARE: PRIME: ____________ EFF.DATE: _____________________ EXTRA:_____________________________
SPONSOR NAME: ____________________________________________ SPONSOR RANK: _____________________
SPONSOR SSN#: _____________________________________________ SPONSOR DOB: ______________________
TRICARE AUTHORIZATION #: _______________________________________________________________________
2. INSURANCE CO.: _____________________________________________ PHONE#: ____________________________
SUBSCRIBER NAME: ______________________________________ DOB: ___________________________________
POLICY ID#: ______________________________________________ GROUP #: ________________________________
SSN#: _________________________________________________ EMPLOYER: _______________________________
3. MEDICAID ____________________________________ RECIPIENT ID#: ___________________________________ ____________________________________________________
(Please complete if client is a minor)
NAME OF ADULT CHILD LIVES WITH. __________________________________________________________________
WHO HAS LEGAL CUSTODY OF THE CHILD? ____________________________________________________________
NAMES OF OTHER PEOPLE LIVING IN THE HOME _______________________________________________________
_____________________________________________________________________________________________________
SCHOOL GRADE _______________________ NAME OF SCHOOL ___________________________________________
TEACHER/COUNSELOR NAMES _____________________________________________ PHONE # ________________
*PLEASE TURN OVER AND CONTINUE ON BACK SIDE* ____________________________________________________
FAMILY PHYSICIAN __________________________________________________________________________________
ALLERGIES _________________________________________________________________________________________
MEDICAL PROBLEMS AND CURRENT MEDICATIONS ___________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
ISSUES BRINGING YOU TO COUNSELING ______________________________________________________________
WHAT YOU HOPE TO CHANGE ________________________________________________________________________
As a courtesy, we generally call to remind our clients of scheduled appointments. This may cause confidentiality concerns for you and because of this, we would like to give you the opportunity to either request or decline this courtesy call. Please do so my initialing your preference:
_________________PLEASE CALL _____________PLEASE LEAVE MESSAGE ______________ DO NOT CALL
WHO REFERRED YOU TO US? _________________________________________________________________________
MAY WE CONTACT THEM TO EXPRESS OUR GRATITUDE? ____________
Providing information on race/ethnicity is voluntary and will be held confidential. The _______________ strives to provide services to all families in a culturally sensitive manner. In order to assist us in meeting the needs of our culturally diverse population, we ask that you complete the following section:
NAME OF PERSON WE MAY CONTACT IN CASE OF EMERGENCY: _______________________________________
ADDRESS: _________________________________________________________________________________________
WORK PHONE: __________________ HOME PHONE: ________________
I AUTHORIZE THIS OFFICE TO RELEASE ANY INFORMATION OBTAINED DURING EVALUATIONS OR TREATMENT OF THIS CLIENT TO THE INSURANCE COMPANY INDICATED ABOVE WHICH IS NECESSARY TO EXPEDITE AND SUPPORT ANY INSURANCE CLAIMS ON THIS ACCOUNT. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES, REGARDLESS OF INSURANCE COVERAGE. I AUTHORIZE THE PAYMENT OF BENEFITS OTHERWISE PAYABLE TO ME DIRECTLY TO THIS PROVIDER. MEDICARE REGULATIONS MAY APPLY.
_________________________________________________ ___________________ Client/Legally Responsible Person’s Signature Date
01/2008 |
|
PLEASE SPECIFY THE CLIENT’S CULTURAL/ETHNIC GROUP: |
|||
|
[ ] White |
|
[ ] Black |
|
|
[ ] Hispanic |
|
[ ] Native American |
|
|
[ ] Asian |
|
[ ] Biracial (biological mother) |
|
|
[ ] Other |
|
[ ] (biological father) |
|