Counseling Services

            Christine C. Becker LICSW, BCD

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New Patient Registration Form

 Please print and fill out this form and bring it with you to your first session. It would also save time if you

can bring with you a photocopy of your insurance card (front and back) as well as any authorizations for

treatment required by your insurance carrier. Thank you. 

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Patient's Full Name (First, Middle Initial, last)                               Patient's social security number  
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Patient's Street Address  
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City                                                                         State                                       Zip Code  
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Patient's date of birth                          Patient's Sex (M or F)                          Patient's marital status (S-M-D-W)   ________________________________________________
Telephone number(s) - (Please list in order of preference)                            Email Address  
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Employer                               Employer's complete address  
______________________________________
Guarantor's Full Name (First, Middle Initial, last) 
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Guarantor's relation to patient (self, spouse, parent)   
______________________________________
Guarantor's street address (if different from above)  
______________________________________
Guarantor's telephone number(s) - (Please list in order of preference)  
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Guarantor's Employer  
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Guarantor's employer's complete address  
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Primary Insurance Co.                                                                         Primary Insurance Co. telephone number  ______________________________________
Do you have a deductible (yes or no)                                              If yes, how much?   ________________________________________________
Claim mailing address  
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Group Name                                          Group/Plan number                              Insurance ID number