Client’s First name

Client’s Last name

Client’s Birthday

Month

Day

Year

Client’s Address 1

Address 2

Zip Code

City

State

Primary Phone

Can we leave a message?

Secondary Phone

Can we leave a message?

Email

Administrative Sex

Male

Female

Please briefly mention who referred you or if you have a preferred clinician.

Who are the services for?

Myself

Someone Else

This application for for someone under the age of 18.

Parent/ Guardian First and last Name

Parent/ Guardian Contact Information

Please Indicate School Child Attends

I give consent to New Purpose Counseling, PLLC. to provide behavioral services for my child.

Parent/Guardian Signature

Policy Information

Insurance Provider

Member ID

Priority

Policy Group

Plan Name

Insurance Card

Provide photos of the front and back of your insurance card to send to New Purpose Counseling PLLC. You can take a picture with your phone or upload a file.

Front of Insurance Card

Back of Insurance Card

Release of Information & Assignment of Benefits

I understand and agree to the following: