PLEASE COMPLETE AND EMAIL TO BCOLETTALICSW@GMAIL.COM

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DATE:   _____________________________________

NAME    _________________________________________________________________________________________________________________________________________________________________________    

ADDRESS_________________________________________________________________________________________________________________________________________________________________________

Date of Birth:__________________________

PLEASE CHECK WITH YOUR INSURANCE COMPANY TO SEE IF YOU ARE COVERED FOR SESSIONS, IF YOU HAVE A DEDUCTIBLE THAT MUST BE MET

BEFORE COVERAGE TAKES EFFECT, AND AMOUNT OF CO-PAYMENT:

MEDICAL COVERAGE TYPE:  _________________________________________.  NUMBER___________________________________

DEDUCTIBLE (IF ANY)_______________________________. CO-PAY (IF ANY)

Phone:    Home    ________________________________   Cell ________________________________    Work____________________________________ 

Marital Status:    Married         Single       Divorced       Widowed

Have you been to therapy before?  When .... and outcome ..... 

Briefly state why you coming into therapy now.

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