CHILD / ADOLESCENT APPLICATION FORM

In order to begin the treatment process 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.

Children and adolescents below 18 years of age should complete the Child and Adolescent Application.

If applying for services for someone 18 or older, please use Adult Form

 

PARENTS' EDUCATION: (Enter last grade completed.)

EMPLOYMENT  STATUS

PATIENT PHYSICAL HEALTH RECORD (To be completed by parent / guardian)

6) Has child or mother had any of the following at birth: (Please check one for each condition.)

Any time after the first fourteen days of life, did your child have the following: (Please Check One.)

INFECTIONS :

7) Do you have a regular pediatrician?

8) Vaccination Records:

11) Has anyone in the family ever had the following?

MONTHLY BUDGET

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

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:

FAMILY INFORMATION

MONTHLY HOUSEHOLD & LIVING EXPENSES

  INSURANCE BENEFITS INFORMATION & PATIENT RESPONSIBILITIES

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

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.

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