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859-474-6440

New Client Form

Thank you for choosing Momentum Couseling! Please complete this form in its entirety and let us know if you have any questions!

PATIENT INFORMATION

Patient First Name

Date of Birth

Patient Last Name

Is the patient a minor?

No

Yes

Sex/ Gender

Male

Female

Social Security Number

If you identify differently, and would like to tell us, please do so.

Parent or Gaurdian's Name

Street Address

City

Region/State/Province

Postal / Zip code

Primary Phone

Secondary Phone

Email Address

Payment Information

How will you pay for services?

Self Pay

Insurance or Medicaid

Insurance Provider or Medicaid MCO

Member ID or Policy Number

Group Number

Upload Picture of Insurance Card

Upload File

Upload supported file (Max 15MB)

Do you have Secondary Insurance?

No

Yes

Secondary Insurance Provider

Secondary Member ID

Secondary Group Number

Who is financially responsible for this patient?

Self

Other

Financially Responsible's Name

Date of Birth

Gender

Male

Female

Social Security Number

Relationship to Patient

Consent to treatment

I certify that I have read, fully understand, and agree to Momentum Counseling's Consent to Treatment and Privacy Practices.

Billing Practices

I certify that I have read, fully understand, and agree to Momentum Counseling's Fee Schedule and Billing Practices.

By signing below, I certify that I am the patient, or the legal guardian or care-taker of said patient.

Upon submission, a copy of this form will be e-mailed to you for your records.

Your Name

Date

Your Signature

Thanks, see you soon!

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1717 Dixie Hwy, Suite 415, Fort Wright, KY 41011 | 859-474-6440

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