Katherine Therrell LPC PLLC
Katherine Therrell LPC PLLC
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. _______________________________________________________
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Will bill Medicaid and most private insurance plans