CLIENT INFORMATION & INTAKE FORM Ken McCarty, LMFT

Licensed Marriage Family Therapist

Discovery Cove Recovery and Wellness Center Eagle River

16600 Centerfield Dr. Suite 203 agle !i"er# $% &&'(( )h*ne+ ,&0(- 6&./'''0 0 Fa1+ ,&0(- 6&./''(0

CONFIDENTIAL
The f*ll*2ing f*rm is f*r inta3e inf*rmati*n f*r th*se 2h* are see3ing mental health ser"ices 2ith Disc*"ery C*"e. C*mpleti*n *f this f*rm is re4uested in *rder f*r a 5etter understanding *f y*urself and efficient treatment t*2ard y*ur mental health. Intake Date GENERAL INFORMATION (Plea e PRINT clea!ly" Cl#ent$ Na%e: Ma#l#n) Add!e : (Include *t!eet+ C#ty+ *tate+ and ,#- Code" Intake conducted by: Date o& '#!t(: E%a#l:

P(one Nu%be! ()lease c#!cle %a#n ph*ne num5er" .o%e+ Ma!#tal *tatu : (Plea e c#!cle" *#n)le *3*3 Nu%be!: /(o to Not#&y #n Ca e o& E%e!)ency: Relat#on (#- to Cl#ent: /o!k+ Ma!!#ed D#0o!ced 1 *e-a!ated Ot(e! Cell+ *e2: (Plea e C#!cle" Male Fe%ale

D!#0e!$ L#cen e: E%e!)ency Contact$ Add!e and P(one Nu%be!:

.o4 d#d you d#d you beco%e a4a!e o& t(# coun el#n) e!0#ce5 EMPLO6ER INFORMATON FOR RE*PON*I'LE PART6 E%-loye!$ Na%e: E%-loye!$ Add!e :(Include *t!eet+ C#ty+ *tate+ and ,#- Code"

6ou! Occu-at#on:

E%-loye!$ P(one Nu%be!: RESPONSIBLE PARTY FOR PAYMENT Responsible party: Add!e (#nclude t!eet+ c#ty+ tate+ and 7#- code" Self Pay Insurance Relationship to client: Medicaid

Phone Numbers (include home, work, and cellular): Social Security Number: DOB: Drivers License:

Cl#ent$ Na%e:88888888888888888888888888888888888 Policy Holders Name: Primary Insurance Name: Add!e ID #:

Policy Holders SSN: Group #:

Policy Holders DOB: Plan Name:

(#nclude t!eet+ c#ty+ tate+ and 7#- code"

Phone Numbers: Deductible: Renewal Date: Co-payment: Percent:

Any restrictions or limitations on policy?

Secondary Insurance Name: *econda!y Pol#cy .olde!$ Na%e: Add!e

ID #: *econda!y Pol#cy .olde!$ **N:

Group #: *econda!y Pol#cy .olde!$ DO':

(#nclude t!eet+ c#ty+ tate+ and 7#- code"

Phone Numbers: Deductible: Renewal Date: Co-payment: Percent:

Any restrictions or limitations on policy?

PLEA*E *IGN AND RET9RN

6# undersigned# ha"e insurance c*"erage 2ith and assign directly t* %en McCarty# MFT all mental health 5enefits# if any *ther2ise paya5le t* me f*r ser"ices rendered. 6 understand that 6 am financially resp*nsi5le f*r all charges 2hether paid 5y insurance *r n*t. 6 here5y auth*ri7e the therapist t* release inf*rmati*n necessary t* secure the payment 5enefits. Signed+ Date+

6# undersigned# 5elie"e the c*st f*r my therapy 2ill 5e c*"ered 5y the 8ictims *f Crime )r*gram. 6 agree t* file a claim 2ith 8ictims *f 8i*lent Crime 2ithin se"en ,(- days and f*r2ard a c*py *f all c*rresp*ndence recei"ed fr*m 8ictims *f 8i*lent Crime t* the therapist. 6 understand that 6 am financially resp*nsi5le f*r ser"ices if my claim is n*t accepted 5y 8ictim 9itness. 6 2ill agree t* ma3e full payment per sessi*n until my claim has 5een appr*"ed. 8ictims *f 8i*lent Crime 2ill reim5urse client directly f*r all c*/payment 2hich are made# *nce the claim has 5een appr*"ed. Signed+ Date

%en McCarty# LMFT : Client 6nf*rmati*n ; 6nta3e F*rm

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