New Client Information Sheet – Minor | Brighter Sand Psychological Services

Minor's Information

Client Name*

First Last

Date of Birth*

Age*

Address*

Street Address Address Line 2 City State Zip Code

Phone*

Email*

Mother

Mother's Name

First Last

Same Address as Minor

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Email

Father

Father's Name

First Last

Same Address as Minor

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Email

Parent/Guardian Marital Status*

How did you hear about us?*

Where do you prefer messages be left?*

Insurance Information

Policy Holder's Name*

First Last

Date of Birth*

Employer of Insured*

Primary Insurance Provider*

Member ID #*

Group #*

Insurance Provider Address*

Street Address Address Line 2 City State ZIP Code

Customer Service Telephone*

I hereby acknowledge that I received an explanation of Dr. Tompkins’ Psy.D. & Associates business practices. I hereby authorize my insurance benefits to be paid directly to Denise Tompkins, Psy.D. & Associates and I hereby authorize the release any information acquired in the course of treatment that is necessary to process insurance claims. I understand that I am responsible for all charges not paid by my insurance. I also agree to pay all collection agency fees should I default in payment.

Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.

Therapists

Administrators