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. _______________________________________________________