KIM HUMPHRIES & ASSOCIATES CLIENT INFORMATION FORM
DSM Code:_____________ (office use)
Name________________________________________________________ Date___ /___ /______
Street Address _________________________________________________ DOB____ /___ /______
City, State, Zip ________________________________________________ Age_________
Home # ( ) _____________ Work # ( )_____________________ Cell # ( )______________________
*Please note which is best contact number
Email ____________________________________________________________________________
Occupation_________________________ Employer_________________________________________
Marital Status: S______ M______ D_______ W______ Sex: M___ F___
Children (and ages)_________________________________________________________________________________________________________
Any previous marriages_______________ If yes, when?_______________ How long?________________
Custody of children by former marriage?_______________________________________________
Religious preference____________________________________________________________________
INSURANCE INFORMATION
Name of Insured_____________________________________________ DOB of Insured____ /____ /____
Client Relationship to Insured___________________________________
Place of Employment____________________________________________________________________________________________________
Employer’s Address_____________________________________________________________________________________________________
Name of Insurance Company_______________________________________________________________
Insurance Address________________________________________________________________________
City_______________________ State_______ Zip ____________________ Phone ( )_______________________
Policy/ID Number # _____________________________________ Group # ________________________
Authorization to Release Information _________________________________________ /____ /______
(Without the above signature, insurance cannot be filed) (Signature) (Date)
Authorization to Pay Medical Benefits to Clinician ___________________________________ /____ /_____
(Signature) (Date)