Who are you scheduled to see? Angela Maes, LISWErin Collins, LISWJen Davis, LMSWElizabeth Riss, LPCCLeon Aragon, LMSWRichard Maestas, LMSWCharmaine Lopez, LMHCTatum Webb, LMSW

Marital Status: SingleMarriedDivorcedSeparatedWidowedCohabitating Spouse Name:  Payment Structure: self-payinsuranceEAP Referral

Emergency Contact:  Phone:   Relationship?

Patient Employer:  Work Phone:

Primary Care Doctor:  Phone Number:

                       Payment Information

Credit Card #:   Expiration Date:

I hereby authorize Healthy Families to use the above credit card information to cover

any copays, coinsurance or self-pay amounts or amounts not covered by my insurance for payment.

Please type your full name to indicate your electronic signature:

Type Full Name: 

                       Responsible Party Information

Name:   Address:  

City:   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming   ZIP Code:

Phone:  Alternate Phone:   Relationship:

                       INSURANCE INFORMATION

Have you contacted your insurance company about this appointment? yes no

Primary Insurance Co.   Phone:

Address:  City:   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP Code:   Name of Insured:   Insured Id #:

Group #:  SSN of Insured:
                             (MM-dd-yyyy)
Date of Birth:

Secondary Insurance Co.   Phone:

Address:  City:   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP Code:   Name of Insured:   Insured Id #:

Group #:  SSN of Insured:  

Is this an Employee Assistance Program Visit (EAP) ? yesno   Auth #:

# of visits:  

If you will be using your commercial insurance once your EAP visits have been exhausted, please fill out insurance information above.

How did you hear about us?   Reason for seeking care?

                       Medical History

Do you have any drug allergies: yesno    What medicines are you allergic to?

What type of reaction do you have?

What medications, including dosages, are you currently taking?

Past hospitalizations?

Are you sexually active? yesno    Are you pregnant or trying to get pregnant? YES-I AM PREGNANTNO

                       ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I have been presented with a copy of Healthy Families's Notice of Privacy Policies, detailing how my

information may be used and disclosed as permitted by federal and state law. I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information:

Restrictions:

Please type your full name here to acknowledge receipt of Privacy notice: 

                       CONSENT TO TREATMENT

I hereby consent to treatment by the staff of Healthy Families. I understand that Healthy Families uses an interdisciplinary approach to treatment and that the staffing about my case may include therapists, and social workers who may confer and consult regarding the best method of treatment. I understand that my treatment will by confidential except in cases of suspected harm to others, suspected physical or sexual abuse of minors or elders, or ordered by a court of law, or for insurance purposes I understand my clinician is required by law to report the above abuses.

I will have the opportunity to discuss with my clinician the nature of my problem, results of the initial evaluation, the treatment plan, alternative treatment, and reasonable foreseeable risks of my treatment.

I understand that my care is payable at the time of service and that I am responsible for the bill unless otherwise specified. I will be provided documentation to file my insurance. A fee is due for any scheduled appointment unless the appointment is canceled twenty-four (24) hours in advance.

Please check here to accept the terms of the Healthy Families's Consent to Treatment

Please type your full name here to indicate your electronic signature:

For: (Child's name):

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