ADULT APPLICATION FORM

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

 

IF PRESENTLY ATTENDING SCHOOL, PLEASE STATE

EMPLOYMENT STATUS

LIST OTHERS IN THE HOME: (Including children)

LIST PREVIOUS THERAPY: (Therapists, Clinics, Hospitalizations)

STATUS OF CURRENT HEALTH:

PAST HEALTH HISTORY:

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

MONTHLY HOUSEHOLD & LIVING 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*****

IF YES

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.