Jamie Martinez, MS, LMFT
Child and Adolescent Therapist
22443 SE 240thSt, Ste 202
Maple Valley, WA 98038
206-225-9551
CLIENT INFORMATION
Date of Initial Session:______Referral Source:______
Client Name: ______DOB:______
Parent’s Name(s): ______
Contact Information: (home)______(cell)______
Address: ______
City: ______Zip: ______
Email address: ______
Okay to send appointment reminders and communicate via email? Yes No
School: ______Grade_____ Dismissal Time: ______
1. Briefly describe current issue.
2. Provide brief history of issue (include precipitators, duration, and previous therapy).
3. List any psychotropic (anti-anxiety, antidepressant, stimulants, etc) medications your child is currently taking and the prescribing doctor.
BILLING
If using health insurance, please complete this section. If not, skip to last section.
Insurance Information: (fill out only if card is unavailable)
Name of insured: ______
DOB of Insured: ______Employer Name: ______
Insurance Company: ______
Policy Number: ______Group Number: ______
Please bring your insurance card with you or provide a photocopy of the front and back of the card.
Release of Information Authorization to Third Party
I (we) authorize Jamie Martinez to disclose case records (diagnosis, case notes, psychological reports, testing results, or other requested material) to the above listed third-party payer or insurance company for the purpose of receiving payment directly to Jamie Martinez.
I (we) understand that access to this information will be limited to determining insurance benefits, and will be accessible only to persons whose employment is to determine payments and/or insurance benefits. I (we) understand that I (we) may revoke this consent at any time by providing written notice, and after one year this consent expires. I (we) have been informed what information will be given, its purpose, and who will receive it. I (we) certify that I (we) have read and agree to the conditions and have received a copy of this form.
Person receiving services (if over 13): ______Date: //_
Parent or guardian signature: ___ Date: //____
Co-payments and private pay payments are due at the time of service. I understand that I am responsible for keeping my account current, regardless of whether insurance pays.
I HEREBY CERTIFY that I have read and agree to the above.
Person responsible for account: (printed) ______
Signature ______Date: __/____/___