FIRST NAME *
MIDDLE NAME
LAST NAME *
MAIDEN NAME
AGE
HOME ADDRESS *
APT *
CITY *
STATE * New York 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 North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ARMED FORCES AFRICA CANADA EUROPE MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC
ZIP CODE *
HOME PHONE
CELL PHONE
WORK PHONE
Primary Email
GENDER
SEX ASSIGNED AT BIRTH
WEIGHT *
HEIGHT *
RACE
ETHNICITY
Name of school
Address
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, Hospitalizations)
LIST PRESENT THERAPY: (Therapists, Clinics, Agencies with Whom You Have an Application at Present)
MILITARY STATUS AND RECORDS
Current Illnesses (including allergies)
Chronic Conditions *
Tobacco Use (Current/past use, amount/frequency, date of last attempt to quit & related prescription history) *
Significant Illnesses *
Hospitalizations
Accidents
SIGNIFICANT FAMILY ILLNESSES: (If NONE, state so)
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: $
Rent/ Mortgage $
Utilities $
Groceries/Food $
Transportation $
Healthcare $
Child Care/ Babysitting $
Alimony/ Child Support $
Loan Payment $
Credit Card $
Other: $
TOTAL MONTHLY EXPENSES $
NAME OF PRIMARY INSURED:
INSURANCE CARRIER NAME AND ADDRESS:
INSURANCE CARRIER PHONE #
INSURED MEMBER ID #
NAME, ADDRESS, & PHONE # OF PERSON RESPONSIBLE FOR BILL IF OTHER THAN APPLICANT:
INSURANCE CARRIER NAME
INSURANCE PHONE #
Signature of Policy Holder