Bob Sklar MFT Counseling

Live a full, more gratifying life

If you are a new Client, Please complete the following form and bring it to your first session.

 

Bob Sklar LMFT

1619 E. Chapman Ave

Fullerton, CA 92831

New Client Information Form

 

Name:(Last)                                                                        (First)                                                            (MI)                        

Address:                                                                                                                                                            

City:                                                                                                State:                                    Zip:                                    

SSN:                                    -                        -                          Birth Date:                        /                        /                        

Home Tel: (         )                                                                        Okay to leave message?            Y            N

Work Tel: (         )                                    ext.                                    Okay to leave message?            Y            N

Mobile:     (         )                                                                        Okay to leave message?            Y            N

E-mail:                                                                                                                                                                        

**Information transferred through e-mail may not be completely secure and might possibly breach confidentiality if another party interferes. I understand and agree to these conditions. Initial:                         

Driver’s License/ID No:                                                            State:                          Expiration Date:                                    

Names of those you will assume financial responsibility on your account:


 

Do you want us to bill your insurance?   Y     N  (circle one)

 

]Name of primary cardholder:                              

 

Subscriber SSN:            -      -      

Date of birth:              /      /      

Insurance Company:                                    

Insurance Phone: (       )                                    

Employer:                                                

Do you have secondary insurance?         Y     N  (circle one)

Name of primary cardholder:                              

Subscriber SSN:      -      -      

Date of birth:              /      /      

Insurance Company:                                                  X                        

Insurance Phone: (       )                                                      Received HIPAA Form

Employer:                                                

FINANCIAL RESPONSIBILITY PARTY NAME:                                                                                                

CLIENT NAME:                                                                                                                                                

I understand that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and the amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse co-issue remittance for the conveyance of credit to my account. However, I clearly understand that all services rendered me are charged directly to me and that I am the party directly responsible for payment. Should this account become delinquent and it is sent for collection, any and all legal fees or collection agency fees, or any associated costs of fees, will be added to the outstanding balance. I also understand that if I suspend or terminate my care and treatment, any fees for profession services rendered me will be immediately due and payable.

SIGNATURE:                                                                                                                                                                    DATE:                                    /                  /