The Therapy Place
                                       Insurance Application For Therapy

Client: ______________________________                Date: ________________
Phone: __________________        DOB: ___________         SSN: _________________        
Address: ______________________________________________________________
If Client is a Minor:
  Mom’s name: ___________________________________________________
  Mom’s Address: _________________________________________________
  Mom’s Phone: ________________________
  Dad’s Name: ____________________________________________________
  Dad’s Address: __________________________________________________
  Dad’s Phone: _________________________
  Other Responsible Party___________________________________________
  ______________________________________________________________
  
Policy Holder: __________________________________        Relationship: ____________
Employer: ______________________________________      Work Ph: _______________
SSN: ________________        DOB: _____________
Primary Insurance Company: _______________________________________________
MH Ph: ______________________        Cust Serv Ph: ____________________________
ID#: ____________________        Group #: ________________

I authorize the release of any psychological information necessary to process my insurance
claims. I authorized direct payment of healthcare benefits to The Therapy Place for any
professional services provided.  The signatures below are effective for the length of time that I
am in treatment at The Therapy Place and for as long as it takes for the claims to be
processed.  
We do not bill secondary insurance. You may submit your bill to them
directly for reimbursement.

_____________________________                        ______________
Signature                                                                   Date

________________________________                   ______________
Witness                                                                       Date

FOR OFFICE USE ONLY

Contact at Insurance Company: _____________________________________________
Claims Address: __________________________________________________________
Precert # __________________________        Effective Date: _______________________
Number of initial sessions authorized _____             Dates of auth ______________________
Co-pay: _____________        
Deductible: ___________   Start Date: ________   Met? Y N   Remains: ___________
Sessions per Cal  or _____________________ year  __________
90847 Covered? Y N  Additional Info:_________________________________________
________________________________________________________________________