Client Information Form

Click here to download Client Information Form pdf

Or fill in the form here and sign and submit below:

    Current Date:

    Referred By:

    Full Name:

    Preferred Name:

    Date of Birth:

    Age:

    Mental Health MEDICATION:

    If covered under spouse/parent's insurance:
    PRIMARY COVERAGE's



    I authorize the release of any medical information necessary to process this claim. I request the payment from my insurance company be made directly to Angie L. Heath, LCSW with Clinical Conversations, Inc or (if utilizing out of network benefits, request payment of benefits either to myself or to the party who accepts assignment below).
    I permit a copy of this authorization to be used in place of the original.

    Signature: (Patient, Parent, or Legal Guardian)

    Date:

    APPOINTMENT REMINDERS

    You can receive an appointment reminder via text. This service is from Jituzu.com which is HIPAA compliant and is no charge to you. We input the minimal information (your name) into their system along with your phone number.
    Would you like to receive appointment reminders?YesNo