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Robert A. Grier
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Client Information
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Client Name:
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First
Last
Date of Birth:
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Sex:
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~ Please Select ~
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Driver's License:
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SSN:
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Home Phone:
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Cell Phone:
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Address:
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Street Address
Address Line 2
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State
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Employer:
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use "n/a" if not applicable
Position:
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Employer Address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer Phone:
Dependent?
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No
Guardian's Name:
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Guardian's Phone
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Guardian's Cell Phone
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Marital Status:
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Single
Married
Separated
Divorced
Widowed
Spouse's Name:
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Spouse's Employer:
*
Spouse's Work No.
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Emergency Contact 1:
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Relationship:
*
Home Phone:
*
Cell Phone:
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Emergency Contact 2:
*
Relationship:
*
Home Phone:
*
Cell Phone:
*
Insured Party
Relationship to Client:
Insurance Company:
Phone:
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Care Physician
*
Policy Number:
Group Number
Dual Coverage?
~ Please Select ~
Yes
No
2nd Insurance Company
Insured Party:
Relationship to Client:
Phone Number:
Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Policy Number:
Group Number:
Client/Guardian Name:
First
Last
Date:
MM slash DD slash YYYY
I verify that the information given is factual and true to the best of my knowledge. I understand that payment, proof of insurance, and/or copay is due at the time of service. I authorize this office to apply benefits on my behalf for the covered services rendered. I certify that the insurance information I have provided is factual and correct. I hereby authorize my insurance benefits to be paid directly to Cogito Mental Health Services and I hereby authorize the release of any pertinent medical information to my insurance carrier.
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Yes
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