ASSOCIATES IN CHRISTIAN COUNSELING
...applying Christ's heart, mind and love to your counseling needs
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
May we leave a message at your home?
May we leave a message on your cell phone?
Patient Information:
Referred by:
Marital Status:
Insurance Information (if applicable):
Phone (on back of card)
Social Security #
Policy Holder Date of Birth:
Group #
Member ID #
Employer:
Employer Phone #
EAP (Employee Assistance Program) Visits: These are different from standard sessions and not all plans have them.
Do you have EAP visits?
If yes, how many?
Authorization #
Effective Dates of Authorization:
TO
Information for Therapist:
Areas of Concern: So that we can place you with the best therapist to meet your needs, please check all that apply to you.
In your own words, briefly describe why you are seeking counseling:
With this option we will discuss payment options when we give you a call to set up your appointment.
Appointment Information:
Preferred Office for Appointments:
Best Day of the Week:
Therapist Preference:
**Please Note: This is a request & we will do our best to schedule you with this therapist.
