Name of Client
*
Client Date of Birth
*
Contact Phone Number
*
Address
*
City and State
*
Zip Code
*
Email Address
*
Name of Insurance Company
*
Member ID
*
Group ID
*
Name and Date of Birth of Insured (if different from client)
*
Relationship to Client
*
Type of Therapy
*
Individual
Couples
Family
Preferred Therapist
*
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