EDWARDS COUNSELING ASSOCIATES by HC12100409328

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									                     EDWARDS COUNSELING ASSOCIATES
Janette E. Edwards, LCSW        Elliot Preshia, LMHC, NCC, CAP       Erika Banks LMHC, CRC
Herb Latney, LMHC               Lynda Walls, PhD                     Rebecca Phillips, LMHC, MA


                           CLIENT INFORMATION REVIEW

Client Name:_____________________________Date of Birth__________SSN_______________
Address:________________________________________Home Telephone_________________

City:_________________________________State______ Office Telephone__________________

Zip_____________ Gender: M_____F____                       Cell Telephone___________________

Marital Status: Single_____Married_____Other_____        Student: P/T____F/T____

Employer__________________________________________________________________

If Minor, Please list parent(s) name______________________________________________

Parent's Date of birth and social security number if different from primary insurance holder
_______________________________________________________________________

                                         Primary Insurance
Insured's Name:_____________________________Employer______________________________

Insured's Date of Birth:________________Insured's SSN__________________________________

Insurance Company__________________________________________EAP (yes or no)_________

Policy No:_____________________________________Group No.__________________________

Authorization Number____________________________No of Sessions Approved______________

Approved Date Span:__________________Customer Service Number:_______________________

Claims Address:___________________________________________________________________

Reason for counseling____________________________________________________________

                                       Secondary Insurance

Insurance Company_____________________________________________

Policy No:_____________________________________Group No.________________________

Claims Address:_________________________________________________________________

Customer Service Number:___________________________________

								
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