Lee Hasty, LCSW , PA
                      Adult Client Information ( 18 years or older )

Last Name: _____________________________________________________________
First Name: ___________________________ M.I. _______ DOB _________________
Address: _______________________________________________________________
City _________________________________State_______________Zip____________
Telephone: Home ______________ Cell _______________ Work _________________
S.S.#: ________________________ Employer ________________________________
Spouse Name: ___________________________ Employer: ______________________
Primary Doctor’s Name ___________________________________________________
Address:   _________________________________________ Phone #: _____________
Responsible Party’s Name: ________________________________________________
Responsible Party’s Address: ______________________________________________
Phone #: Home _______________ Cell _______________ Work _________________

Insurance Policy Holder Information:
Last Name ________________________ First Name _____________________ M.I. ___
Date of Birth: ______________________ S.S.# ____________________________
Address: ________________________________________________________
City ________________________________ State ___________ Zip __________
Employer ____________________________________________________
Relationship to Client: __________________________________________
Primary Insurance Information
Name of Insurance: _______________________________________________________
Address to mail claims: ____________________________________________________
Individual Policy # / ID #: __________________________________________________
Group Policy #: ___________________________________
Phone # for mental health benefits: _________________________________________
Authorization # : ________________________________________________________
Secondary Insurance(* you must have Medicare or Medicaid for secondary billing )
Name of Insurance: ______________________________________________________
Individual Policy # / ID #: _________________________________________________
Group Policy #: ______________________________________________
Phone # for mental health benefits: ___________________________________________
Address to mail claims: ____________________________________________________

   I authorize the release of any psychological information necessary to process my
insurance claims. I authorize direct payment of healthcare benefits to Lee Hasty, LCSW , PA
for professional services provided. The signature below is effective for the length of time I
am in treatment at Lee Hasty, LCSW , PA and for as long as it takes for my claims to be
processed.

_________________________________________________           _________________
Signature                                                                                     Date