Adult Services Application Form Step 1 of 9

After speaking with our intake coordinator (212-838-4333 ext. 137), please provide us with the following information.

Answers are not saved until you click the final “Submit” button at the bottom of the page. Until that point, you can review and change any answers as needed.

Adults 18 years old and older should complete the Adult Application.

If applying for services for someone younger than 18 , please use Child and Adolescent Form

FIRST NAME *

MIDDLE NAME

LAST NAME *

MAIDEN NAME

DATE OF BIRTH *

AGE

HOME ADDRESS *

APT *

CITY *

STATE *

ZIP CODE *

HOME PHONE

CELL PHONE *

WORK PHONE

Primary Email *

GENDER *

SEX ASSIGNED AT BIRTH

WEIGHT *

HEIGHT *

RACE *

ETHNICITY *

EDUCATION *

Grammar School
High School
College
Other

U.S. CITIZEN:

IF PRESENTLY ATTENDING SCHOOL, PLEASE STATE

Name of school

Address

EMPLOYMENT STATUS

Occupation

How long?

Employer

Address

EMERGENCY CONTACT *

PHONE *

RELATIONSHIP *

PLEASE STATE THE HOURS + DAYS YOU WILL BE AVAILABLE FOR APPOINTMENTS: (Mon-Fri 9am-9pm)

REASON FOR SEEKING TREATMENT

HOW DID YOU HEAR ABOUT THE KAREN HORNEY CLINIC? (Source of referral)

LIST OTHERS IN THE HOME: (Including children)

LIST PREVIOUS THERAPY: (Therapists, Clinics, Psychiatric Hospitalizations)

LIST PRESENT THERAPY: (Therapists, Clinics, Agencies with Whom You Have an Application at Present)

MILITARY STATUS AND RECORDS

STATUS OF CURRENT HEALTH:

Current Illnesses (Must list allergies, if any)

Chronic Conditions *

Tobacco Use (Current/past use, amount/frequency, date of last attempt to quit & related prescription history) *

PAST HEALTH HISTORY:

Significant Illnesses *

Hospitalizations

Accidents

SIGNIFICANT FAMILY ILLNESSES: (If NONE, state so)

CURRENT MEDICATIONS: (Including Dosage, If NONE state so) *

List medication, strength (mg) and dosage for each

MONTHLY BUDGET

If you will not be using insurance, please complete the below Monthly Budget Information:

FAMILY INFORMATION

Applicant’s Gross Monthly Income $

Applicant’s Other Monthly Income (e.g, social security, alimony, pension) $

Spouse’s Name

Spouse’s Gross Monthly Income $

Spouse’s Other Monthly Income (e.g, social security, alimony, pension) $

TOTAL MONTHLY INCOME: $

MONTHLY HOUSEHOLD & LIVING EXPENSES

Rent/ Mortgage $

Utilities $

Groceries/Food $

Transportation $

Healthcare $

Child Care/ Babysitting $

Alimony/ Child Support $

Loan Payment $

Credit Card $

Other: $

TOTAL MONTHLY EXPENSES $

Additional Expenses

List any other bills not listed, and specify frequency (monthly, weekly, etc.)

INSURANCE BENEFITS INFORMATION & PATIENT RESPONSIBILITIES

*****PLEASE MAKE SURE THE BELOW INFORMATION IS COMPLETE & SIGNED*****

NAME OF PRIMARY INSURED: *

INSURED RELATIONSHIP: *

Self
Spouse
Dependent

INSURANCE CARRIER NAME *

INSURANCE CARRIER ADDRESS:

INSURED MEMBER ID # *

INSURANCE CARRIER PHONE # *

NAME, ADDRESS, & PHONE # OF PERSON RESPONSIBLE FOR BILL IF OTHER THAN APPLICANT:

DO YOU HAVE SECONDARY INSURANCE: *

IF YES

INSURANCE CARRIER NAME

INSURANCE PHONE #

I hereby assign the insurance benefits to which I may be entitled to the Karen Horney Clinic, Inc. and I authorize payment of these to be made directly to said clinic. I authorize the Karen Horney Clinic, Inc. to communicate any pertinent data to my insurance company regarding this assignment. I also understand that if for any reason my insurance does not cover my expenses that I will be held responsible for prompt payment of any monies due:

In-Network Insurances Please be prepared to pay before each appointment. You are responsible for any deductible, copay and/or coinsurance indicated by your insurance plan, including the full balance due to termination of coverage. You will be responsible for “non-covered” services as deemed by your carriers. NOTE: Some insurance carriers may require that you notify them of your visit with us. Please contact them to avoid additional financial responsibility.

Out-of-Network Insurances Please be prepared to pay before each appointment. You are responsible for 100% of the fee.

Signature of Policy Holder *

Date *

Upload Insurance Cards: front and back

Click or drag files to this area to upload. You can upload up to 4 files.

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Once you have completed this form, you will be redirected to Step 2: Patient Consent for Limited Email and Text Communications