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Sahar Sara Teimoori, L.C.S.W., Psy.D. Hope Psychology Group, Inc.
NEW CLIENT ONLY - OFFICE POLICY PACKET
PLEASE ANSWER ALL THE QUESTIONS ON ALL THE PAGES IN THIS PACKET AND HAVE YOUR
INSURANCE CARD AND DRIVER'S LICENSE READY
Client's Name
*
Date of Birth
*
+
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone (Home)
*
Business
Cell
*
Occupation
*
Employer's Name
*
Soc. Sec. No.
*
Email
*
Driver's License
*
Marital Status
*
Single
Married
Divorced
Separated
Spouse's Name
Emergency Phone No.
*
Primary Insured's Information:
Name of Insurer (s):
*
Insurance Phone#
*
Primary Insured's Name:
*
Relationship:
*
Date of Birth:
*
+
Insurance ID No.:
*
Driver's License#:
*
Is there a secondary Insurance?
*
YES
NO
Name of Insured
*
Relationship:
*
Date of Birth:
*
+
Insured Phone No.:
*
Soc. Sec. No.:
*
Insurance ID No.:
*
Group No.:
*