Adult – Intake Form

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Health Information
Personal Information
Insurance Information
WE ONLY ACCEPT THE FOLLOWING INSURANCES: TRICARE, CIGNA, ANTHEM BCBS, UNITED BEHAVIORAL HEALTH, Medicaid and CHP Plus.
IF YOU DO NOT QUALIFY, YOU WILL BE CHARGED ON A PER SESSION BASIS.
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FINANCIAL RESPONSIBILITY AND CONSENT TO TREAT OR PROVIDE SERVICES: I understand that I am responsible for payment of services rendered at time of service. I am also giving Janice Van Anrooy, MA, LPC, permission to treat the above stated patient and to bill insurance for services rendered. I have also read and understand the HIPPA Privacy Act Information included in this intake documentation.