KATHERINE B. THERRELL, LPC, PLLC

INTAKE INFORMATION

PATIENT’S NAME___________________________________________________________________                                                           FIRST                    INITIAL                                 LAST

PARENTS OF MINOR__________________________________________________________________

ADDRESS________________________________________________________________

CITY______________________________________________STATE_____ZIP_________

HOME PHONE___________________ PATIENT’S BIRTHDAY______________________

REFERRAL SOURCE ______________________________________________________

INSURANCE INFORMATION

INSURED’S NAME AND ADDRESS_______________________________________________________________

SS#______________________ INSURANCE COMPANY___________________________

ADDRESS_______________________________________________________________

GROUP NO. ______________INSURED’S EMPLOYER____________________________

WORK PHONE NO. _______________________________________________________