Dr. Steve's forms - Northwest Family Counseling Services360.479.6327

Dr. Steve Wexler's Forms

Client Information

Name *

First

Last

Email *

Primary Phone Number *

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Alternate Phone Number *

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Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Social Security Number *

If married, how long? *

Employer *

Employer Address *

Line 1

Line 2

City

State

Zip Code

Country

Work Phone Number *

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Can we call work? *

Yes No

Person Financially Responsible *

Relationship *

Social Security Number *

Date of Birth *

Address if different *

Line 1

Line 2

City

State

Zip Code

Country

Name of Spouse/Parents/Guardians *

Emergency Contact and Relationship *

Emergency Contact Phone *

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Children/Siblings in Household *

Names/Sex/Ages *

Number of Children in Family of Origin *

Sibling position in family of Origin *

Medication you are presently on *

Physician *

Physician Phone Number *

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Insurance Information

Primary Insurance

Name *

First

Last

Relationship *

Social Security Number *

Date of Birth *

Employer *

Occupation *

Employer's address *

Line 1

Line 2

City

State

Zip Code

Country

Employer's Phone Number *

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-

Insurance Company *

Group Number *

Subscriber Number *

Annual Deductable *

Has it been met? *

Yes No

Is pre-authorization required? *

Yes No

Has it been obtained? *

Yes No

Secondary Insurance

Subscriber's Name *

First

Last

Relationship *

Social Security Number *

Date of Birth *

Employer *

Occupation *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Employer's Phone Number *

-

-

Insurance Company *

Group Number *

Subscriber Number *

Annual Deductable *

Has Deductible been met *

Yes No

Is pre-authorization required? *

Yes No

Has it been obtained? *

Yes No

Do you have other insurance? *

Yes No

Name of Insurance *

I agree to inform Northwest Family Counseling Services if any information changes on this form. I understand it is my responsibility to confirm insurance benefits and that I am responsible for all fees, whether or not I have insurance coverage. Northwest Family Counseling Services has my permission to bill my insurance company. I authorize the release of any medical information necessary to process these claims. I understand that I am responsible for all charges for services provided, including late, cancellation (less than 24 hours notice) and no-show fees, whether or not paid by insurance. I understand that I will be held additionally responsible for all collection and attorney fees necessary to collect fees owed. I understand that all co-payments need to be made at the time of service and that additional billing charges and statement fees may be added to co-payments not made at the time of the session. I understand that I am personally responsible to confirm my insurance benefits and whether or not my therapist is covered by my insurance.

By checking this box I agree with the statement above. *