New Client Form

Ann E. Drouilhet, LICSW,LMFT NEW CLIENT INFORMATION

42 Washington Street, Suite 210

Wellesley, MA 02481

adrouilhet@gmail.com

Client Information:

Date Name Address Phone Number Date of Birth Marital Status Your email Referred By: Medications: Physician: Past Hospitalizations In the event of an emergency please contact: Relationship to emergency contact: Emergency contact phone number:

School Information:

School Name School phone number: Grade:

Employment Information:

Employment: Business Name Business Phone

Family Members:

Insurance Information New Client - Ann E. Drouilhet, LICSW :

Insurance:

Client Name Insurance Plan Name Address City State Phone Subscriber Name (Insert "Same" if same as patient) Subscriber Address (Insert "Same" if same as patient) Relationship to patient Subscriber Date of Birth Subscriber ID Subscriber Group Number Subscriber Policy Number Diagnosis Code

CLIENT or AUTHORIZED PERSON'S SIGNATURE REQUIREMENTS

Release of Information

I (client, parent or guardian) authorize the release of any medical or other information necessary to process insurance claims. I also request payment of government benefits either to myself or to the party who accepts assignment below.

Signature (client/authorized signature)

Date

Assignment of Benefits

I authorize payment of medical benefits to Ann Drouilhet, LICSW:

Signature (client/authorized signature)

Date

Confidentiality/Privacy Policies

I have received and understand my rights to protect my privacy and the confidentiality of services provided

Signature (client/authorized signature)

Date

Cancellation Policy

I request that you give me at least 24 hours notice if you must cancel an appointment. If you must cancel on short notice, please call to let me know that you are not coming. I charge my usual fee for short cancellations or missed appointments.

Please be aware that insurance companies will not pay for canceled or missed appointments.

I have read and understand the cancellation policy.

Signature (client/authorized signature)

Date