Client Intake Form

Regina Katz, LCSW

Email: Reginakatz79@gmail.com

(516) 524-7574

FAX: (516) 626-1568

Name

Address

City

State

Zip

Cell

Home Phone

Date of Birth

Who referred you?

(ONLY FILL OUT IF APPLICABLE)

Is client currently under the care of a MEDICAL PROFESSIONAL?

Name

Phone Number

Is client currently under the care of a NUTRITIONIST?

Name

Phone Number

Is client currently under the care of a PSYCHIATRIST?

Name

Phone Number

Medication and Dosage

(PLEASE ONLY FILL OUT THIS SECTION IF PATIENT IS A MINOR)

Current School and Grade

Mother's Name

Mother's Cell

Mother's Email

Father's Name

Father's Cell

Father's Email

Payment Information

Patient is responsible for payment at the time of sessions, unless another arrangement has been made at the initial session. I am not a participant on most insurance plans. I would be happy to provide you with a statement to submit to your insurance carrier on a monthly basis.

If you are unable to keep your scheduled appointment, I respectfully request 24 hour advance notice for your cancellation, or you will be responsible for the fee.

Person Responsible for Payment

Email to use for sending statements

The following is only necessary to provide if reviewed in initial session:

Insurance Company

Policy Number

Policy Holder's Name

Policy Holder's Date of Birth

Claims Address

Phone Number for Claims submission

The following signature (parent's signature if client is under 18) is confirming their understanding of the above.

Signature

Date

Thank you, I look forward to working with you!

Regina Katz

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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