Child - Intake Form - Janice VanAnrooy, MA, LPC

Name *

Date of Birth *//

Mobile Phone *

Home Phone

Email *

Address *

Address Line 1

City

State

Zip Code

Health Information

Physician *

Phone

Psychiatrist

Phone

Dietitian

Phone

Medications and/or Supplements:

Prior Mental Health Treatment:

Personal Information

Guardian Name *

Guardian Occupation *

Second Guardian Name

Second Guardian Occupation

School Name *

Insurance Information

WE ONLY ACCEPT THE FOLLOWING INSURANCES: TRICARE, CIGNA, ANTHEM BCBS, UNITED BEHAVIORAL HEALTH, Medicaid, UMR and CHP Plus.
IF YOU DO NOT QUALIFY, YOU WILL BE CHARGED ON A PER SESSION BASIS.

Which is your Insurance provider? *

Policy Holder: *

Policy Holder ID: *

For all Tricare members please submit sponsor ssn not DoD numbers*

Policy Holder Date of Birth: *//

Group Name

Group Number

Referral Source: *

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.

Acknowledgments *

I hereby consent to Fee Schedule and Financial Policies
I hereby consent to Disclosure Statement
I hereby consent to HIPAA Policy

Guardian(s) Signature *

Patient Signature (if between ages 13 and 18) *