Client Information 2021 | Behavioral Therapy

Client Information

Tri-Cities Behavioral Therapy 321 West Walnut Street Box#2

Johnson City, Tennessee 37604

Phone: 423-202-3622

Fax: 423-631-0019

Please fill in all required ( * ) fields.

Date

Client Last Name

Middle Initial

Birthdate

Client First Name

Age

Parent/Guardian Name

Address

City

State

Zip Code

Mailing address if different

Home Phone#

Work Phone#

Mobile Phone#

Emergency Contact Person

Emergency Contact Relationship to Client and Phone Number.

Physician Information

Physicians Name

Physicians Phone#

Physicians Address

Current Diagnosis

Insurance Information

Clients Name and Social Security Number

Parents or Guardians Name

Primary Insurance

Primary Insurance Company

Primary Insurance Group Number

Primary Insurance Subscriber's Name

Primary Insurance Subscriber's Date of Birth

Primary Insurance Policy Number

Primary Insurance Member ID

Primary Insurance Employer

Primary Insurance Subscriber's Relationship to Client

Secondary Insurance

Secondary Insurance Company

Secondary Insurance Group Number

Secondary Insurance Subscriber's Name

Secondary Insurance Subscriber's Date of Birth

Secondary Insurance Policy Number

Secondary Insurance Member ID

Secondary Insurance Employer

Secondary Insurance Subscriber's Relationship to Client

Please let staff know if you have any other insurance.

Medical History

Is your child currently seeing a Psychiatrist, Psychologist, Social Worker, or Counselor? If yes, please list their name(s) and numbers:

Please list any medical problems that we need to be aware of?

Food or Drug Allergies

Other providers involved with your child's care (i.e. PT, OT, Speech, etc.)

Please list any behavioral health or other intensive autism related services and dates:

Educational Information

What school does your child attend?

County of Childs School

What grade is child in?

Does child have a current IEP

Parent or Guardian Signature

I certify that I have answered all the information on the Client Information Form to the best of my knowledge and the information is current and correct. (Print or type signature)

If you would rather print this form and return to us in person or by mail, click on the button below labeled "Printable Forms".

Our address is. Tri-Cities Behavioral Therapy 321 West Walnut Street Box #2 Johnson City, Tennessee 37604

Printable Forms

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