New Patient Form – Sabrina Walters Counseling

Patient/Client Name (first/last)*

Briefly describe why you are seeking mental health services at this time?*

Patient's Date of Birth*

Age of Patient / Client

By whom were you referred?

Are you a returning patient? YesNo

Payment Responsibility

How are you paying for your visit?* InsurancePaying Privately

If you selected "Insurance", please provide the following information

Insurance Provider -

ID / Group # -

Birth Date of Insured -

Responsible Party -

Personal Contact Information

The following information will be used to contact you to make an appointment. Please complete this section if it differs from the Insurance Card Holder’s Information above.

Your Relationship to the Patient/Client

Your Email*

Primary Phone Number

Secondary Phone Number

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country