1. Demographic and Insurance Information

* 1. Identifying Information

* 6. Responsible Party (if different than client)

* 7. Insurance Information. If you would like me to bill your insurance company at no charge to you, please take out your insurance card and fill in ALL of the fields below. If the information is not on your card, please write NOT ON CARD in the appropriate field. Any missing information will delay billing your insurance company.

8% of survey complete.