Intake FormPlease complete this form completely with accurate information. Failure to do so may delay the scheduling process. Patient Name * First Name Last Name Preferred Name * Date of Birth * Race * Marital Status * Gender Identity * Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Session Type * Select One Individual Couples (both partners will need to complete an intake) Reason for Visit * Responsible Party Information Primary Insurance * BCBS, Cigna, Aetna, UHC, et... Name * Name of Policy Holder First Name Last Name Subscriber ID# * Group # EAP Authorization # Referral Source * How did you hear about us? Name of Physician Physician Phone (###) ### #### Physician's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name any medications you are taking and for what condition(s) * If none (N/A) Emergency Contact Name * First Name Last Name Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Relationship to Patient * Assigned & Release Patient/Parent or Guardian Signature (if minor) * I hereby authorize payment of medical benefits to this Physician and/or Licensed therapist for all services rendered by them. I also authorize the release of any information necessary to process these insurance claims. No Call/No Show Policy * Please be aware that making and paying for an appointment with T. Greene Consulting and Therapeutic Services but not showing up for your appointment will result in a $50 no call no show fee and a total loss of any payments made. No refunds will be made and you will not be able to transfer any previous payments to a new appointment date/time. You will be responsible for paying for any new appointments scheduled. Late Policy * For both in person and telehealth sessions, there will be a $35 fee that results in client showing or logging on for an appointment within 15 minutes past your scheduled time without notifying our office. Date MM DD YYYY Thank you!