Adult Information Form

PLEASE COMPLETE THE ENTIRE FORM. PLEASE ALLOW AT LEAST 15 MINS TO COMPLETE IT. YOU WILL NEED TO PROVIDE YOUR INSURANCE INFORMATION SO PLEASE BE PREPARED TO ENTER THAT INFORMATION. ALSO PLEASE SIGN ALL THE CONSENT FORMS AND SIGN FINALLY AT THE END. THANK YOU! Please refer here for our privacy policy.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

SMS Policy - We use business text to confirm and schedule appointments and for general correspondence and not marketing purposes.

By checking this box, you agree to receive text messages from The Eupatheia Center. You may reply Stop to opt-out at any time!

Email Address *

Date of birth: * +

Gender: *

Faith:

Years of education: *

Occupation:

Insurance Information

Insurance Provider: *

Member ID:

Group:

Primary policy holder name (if under a partner/parent): *

Primary holder D.O.B: * +

Please provide your credit card information for copays/coinsurance/payment/terminated insurance. Thank you.

Card number *

Expiration *

Zip code *

Name on card *

Previous Psychological Services

Have you seen a therapist, psychologist or psychiatrist before? *

Yes

No

Who did you see, for how long, why, and what was the outcome/diagnosis? *

Why are you seeking counseling/a psychologist now? *

How long has the problem lasted? *

Under what conditions does the problem get worse? *

Under what conditions does the problem get better? *

Family Situation

Marital Status: *

How long have you been married? *

How many times have you remarried? *

People living in the home:

	Name	son/daughter/partner/parent	Age
Person 1	Name	son/daughter/partner/parent	Age
Person 2	Name	son/daughter/partner/parent	Age
Person 3	Name	son/daughter/partner/parent	Age
Person 4	Name	son/daughter/partner/parent	Age
Person 5	Name	son/daughter/partner/parent	Age
Person 6	Name	son/daughter/partner/parent	Age

Private/Self-Pay	Aetna	United Healthcare	Cigna
BCBS/Anthem	UMR	Tricare	Peachstate
Amerigroup	Caresource	Ambetter	Medicare
Humana	Optum	First Health Network	EAP
Other Other