Lee Hasty, LCSW , PA

                              Child / Adolescent Information ( 17 years old and younger )



Full name: ______________________________________________________________

DOB __________________ S.S.# _______________________

Address: ________________________________________________________________

Mother’s or Legal Guardian’s Name: _________________________________________

Social Security #: ____________________________________

Address: ________________________________________________________________

Phone: Home __________________ Cell__________________Work______________

Father’s or Legal Guardian’s Name: __________________________________________

Social Security #: ____________________________________

Address: ________________________________________________________________

Phone: Home___________________Cell__________________Work________________

Person Responsible for Bills: ________________________________________________

Address: ( if different from above ) ___________________________________________

__________________________________________Phone ________________________

Primary Care Physician Name: ______________________________________________

Address: ________________________________________________________________

Phone ________________________________



Primary Insurance Information

Insurance Co.: _______________________________________________

Individual Policy # / ID #: _______________________________________________

Phone # for mental health benefits: ________________________________________

Name of Insured ( policy holder ): ____________________________________________

Date of birth: _________________________ S.S.#: _____________________________

Employer: _______________________________________________________________

Group ID #: ___________________________

Secondary Insurance (applies only if your child / adolescent has Medicaid )

Name of Insurance: _______________________________________________________

Phone #: ____________________________ Policy #: ____________________________

Name of Policy Holder: _________________________________________DOB_______





   I authorize the release of any psychological information on the above child or adolescent that is
necessary to process his / her 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 the above child / adolescent is in treatment at Lee Hasty, LCSW , PA and for as long as it
takes for the insurance claims to be processed.



_______________________________________________        ____________________

Signature of Parent / Legal Guardian / Responsible Party           Date