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New Client Information for Dr. Abrams

This form is to be completed by the individual seeking care from Dr. Abrams; if that individual is under the age of 18, the form needs to be completed by the parent or guardian

*Name:		*Email:

*Address:

Occupation:		City/State/Zip:
Work Phone:	--	Home Phone:	--
Cell Phone:		*SS#:

Date Of Birth:		Referred By:
Insurance Company:
Plan#:		Group#:
Name Of Insured:		Secondary Insurance:
Plan#:		Group#:
Please list any medications or medical conditions that you believe might be relevant to your treatment with Dr. Abrams.

I understand that all conversations and communications with Dr. Abrams are confidential except for reports of child abuse and threats of violence against a specific individual. Dr. Abrams will keep all of my records secure and confidential. I give Dr. Abrams permission to bill my insurance carrier for services he/she has provided to me. Should these payments come to me, I understand that they are due to Dr. Abrams. Dr. Abrams requires 24 hours notice to cancel my appointment and if I fail to make this cancellation I am personally responsible for the entire session fee.