How to Know If Therapy Is Helping You

Personal Information

Patient Contact Information

Please complete the following section with your legal information as it appears on your insurance card (if applicable):

First Name

Last Name

Date of Birth

Phone Number

Email

Address

Street Address City State / Province / Region ZIP / Postal Code

Patient Personal Information

Gender Assigned at Birth (sex)

Male

Female

Gender Identity

Pronouns

Sexual Orientation

Marital Status

Responsible Party Information

Are you completing this form for someone else?

Yes

No

What is your relationship to the patient?

Are you the responsible party for billing?*

Yes

No

First Name

Last Name

Phone Number

Email

Address

Street Address City State / Province / Region ZIP / Postal Code

Gender Assigned at Birth (sex)

Male

Female

Legal Guardian Information

Are you completing this form for a minor?

Yes

No

First Name

Last Name

Legal Guardian Relationship to Patient

Phone Number

Email

Address

Street Address City State / Province / Region ZIP / Postal Code

Do you have a custody agreement on file?

Yes

No

Insurance Information

Insurance Carrier

Member ID

Group Number

Effective Date of Coverage (EDOC)

Coverage Type

Name of Policy Holder (if other than patient)

Relationship to Patient

Insurance Carrier Phone

Do you have a secondary insurance?

Yes

No

Secondary Insurance Carrier

Member ID

Group Number

Effective Date of Coverage (EDOC)

Coverage Type

Name of Policy Holder (if other than patient)

Relationship to Patient

Insurance Carrier Phone

Payment Information

A credit card is required to be placed on file, and please note it is fully encrypted within our system. No one can view or access your card information. Our benefits department will verify your insurance coverage to confirm that services are in-network. Your card will only be charged if a copay or coinsurance applies, typically 1–3 business days after your appointment. For this initial appointment, there is no late cancellation or missed appointment fee; however, we ask that you call our oﬃce if you need to cancel. Additional information can be found under our financial policies in your intake paperwork.

Card Type

Card Number

CVV

Expiration Date

Cardholder Name (as it appears on the card)

Billing Street

Billing Zip Code

Visit Reason

May we let your provider know the reason for your visit?

Select your visit reason below

How did you hear about us?

A Friend or Family Member

My Doctor

Online Search

Radio Ad

Social Media

Other

Blog

How to Know If Therapy Is Helping You

Jump to Section

TAGS:

You Deserve to Feel Better

Call Us at:

Thank you for your interest in booking with Safe Harbor!

Personal Information

Legal Guardian Information

Insurance Information

Payment Information

Visit Reason

Blog

How to Know If Therapy Is Helping You

Jump to Section

TAGS:

Related Articles

Mindfulness Practices to Reduce Daily Anxiety

Understanding Anxiety: Signs, Symptoms, and When to Seek Help

Share this article

Author

Find the Right Support, Right Now

You Deserve to Feel Better

Call Us at:

Personal Information

Legal Guardian Information

Insurance Information

Payment Information

Visit Reason