Section I: Patient Information
Name:___________________________________Age:_______ I Prefer to be called: _______________
Circle Appropriate Status: Minor Single Married Widowed Separated Divorced
Person to contact in case of emergency____________________________ Phone__________________
Section II: Responsible Party
Name:_____________________________________________________
Relationship to Patient: Self Spouse Parent Other
Address:____________________________________City:_______________State:_______Zip________
Phone (___) _______________ Work Phone (___) ______________ Cell Phone (___) _______________
The best time to contact me is:________ A.M. / P.M. on Home / Work / Cell number
Leave a message Yes / No
Email Address ________________________________
(I prefer to use email only for scheduling purposes to protect the confidentiality of your health and
personal information. For any detailed information or inquiries, please call 443-975-6577 to talk with me
or set up an appointment in person)
How will you be paying for therapy?
Circle: Self-pay / Insurance (See form) / Bishop’s Pay
For Self-pay:
I authorize Sandcastle Family Counseling to charge my credit card for services. Initial: ______
Card number: _________________________________ Expiration date: __________________
CVV code: ______ Billing zipcode: ________________
I decline automatic charges. I will be paying via CASH / CHECK. Initial: _______
For Insurance pay, see Insurance form (I only accept Regence BCBS), as well as Insurance section of
Consent document.
For Bishop’s pay:
Name of Bishop: _____________________________________
I authorize Sandcastle Family Counseling to contact my bishop for billing purposes. Initial: _______
I authorize _________________________ (name of therapist) to exchange two-way information with
my bishop for treatment planning purposes. Initial: ________
I decline authorization of exchange of information between my therapist and my bishop. Initial: ______
I agree to the above-mentioned contract for paying for therapy services.
________________________________
___________________
Client signature
Date
________________________________
___________________
Therapist signature
Date