PsychotherapyForWomen.com (917)246-0016 vickibonnell2@gmail.comPATIENT INTAKE FORM 1
Name_________________________________DOB___/___/___
Cell Phone________________Home Phone__________________
Billing Address__________________________________________
City________________________________________State__________ZIP_________________
Email Address_____________________________Referred by__________________
Primary Physician__________________________
Gender Assigned at Birth (Circle) Female Male Emergency Contact Information:
Name_________________________Relationship to Patient___________
Cell#:________________________________Home Ph#:____________________________
Credit Card Authorization
Please indicate the form of payment you wish to use for any services rendered through this practice. The following forms of payment are accepted, VISA. MASTERCARD DISCOVER AMERICAN EXPRESS Service fees will be deducted from the designated account at the time services are rendered for Tele-health sessions.Patient Information
Patient Name______________________________Date of Birth____________________
Cardholder Information: (please circle) (Patient) Same as above OR (Other) (relationship to patient)__________________
Credit/Debit Card Information
Card Type (circle one) VISA Mastercard Discover American Express
NAME ON CARD:___________________________________
CARD#:___________________________Exp Date:___/___. CVV:_____
Cardholder Signature_________________________________Date______________
A no show/missed appointment or less than 24 hours notice for a canceled appointment will be charged as full session unless rescheduling was possible.