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