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May We Contact You?

Parent/Guardian Name:

Address:

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E-mail:

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City:

Grade in School

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Therapist Name

Client Name:

Client’s Date of Birth    MM/DD/YYYY

Primary Insurance

Social Security Number

Single or Married?

Insured’s Name:

Insured’s Social Security

Insured’s DOB   MM/DD/YYYY

Insurance Company

Insured ID

Policy Group

*****Phone Number on the back of the card for Mental Health Benefits

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you can click on this link and print and complete the top half of the form below.   Please fax this form  to

214-509-6887.