Name: Tompkins & Associates
Address: 1801 N. Mill Street Suite C, Naperville, Illinois, 60563, US

Minor's Information
Client Name*
First Last
Date of Birth*
MM slash DD slash YYYY
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?*
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Insurance Information
Policy Holder's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
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*
Name
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Minor's Information

Mother