Sahar Sara Teimoori, L.C.S.W., Psy.D. Hope Psychology Group, Inc.

NEW CLIENT DEMOGRAPHIC & BILLING INFORMATION SHEET

PLEASE Fill OUT COMPLETELY & RETURN WITH COPY OF DRIVER LICENSE & INSURANCE CARD(S)

Client's Name *

Date of Birth * +

Previous Names or Aliases *

Soc. Sec. No. *

E-mail *

Driver Lic No. *

Phone (Home) *

(Work)

Cell *

Marital Status *

Spouse's Name & Phone No. *

HOME ADDRESS

Street *

City *

State *

Zip *

MAILING AND BILLING ADDRESS

Street *

City *

State *

Zip *

Phone (Home) *

(Business) *

(Cell) *

Employer

Name *

Address *

Phone *

Your Occupation *

EMERGENCY CONTACT

Name *

Relationship *

Phone *

PRIMARY INSURANCE

Carrier: *

Member ID No. *

Phone *

Policyholder: Name *

DOB * +

Relationship *

Employer Name and Address: *

SECONDARY INSURANCE

Carrier: *

Member ID No. *

Phone *

Policyholder: Name *

DOB * +

Relationship *

Employer Name and Address: *