Client Demographic Information

Hello,

Thank you for choosing Your Safe Space (YSS). We look forward to building a positive and productive therapeutic relationship with you. To begin services, we are required to collect certain identifying information. This allows us to verify your identity, provide appropriate care, and submit claims to your insurance on your behalf. Please note that if this information is not provided, your insurance company may deny coverage, which could result in you being responsible for the full cost of services.

If you have any questions or concerns, please contact us at (301) 459-0708.

Email

First name

Last name

Client status

I am a new client

I am an existing or returning client

Birthday

Month

Day

Year

Phone (mobile)

Phone (home)

Address

Client involvement in legal action ie. CPS/CriminalCourt/Mental Health/Immigration, etc (please read consent form for court matters) Mental Health Court clients please contact the office for further instruction after completing this form.

Preferred contact method

Phone

Email

Text

Other

(For *MINORS ) We need the Parent/Guardian first & last name, DOB, contact phone number, and email address for Insurance Authorization Purposes & Consent. Type N/A if this does not apply to you. Name

Parent or Ins Carrier Date of Birth

Phone

Email

Photo ID (govt. issued ID)

Photo ID (govt. issued ID) - If client is a minor - parent is to upload their ID

Insurance Card upload - front & back

Insurance Policy Number

Insurance Policy Holder Name, DOB, and Relationship to client

If using *EAP (Employee Assistance Program), upload the letter of authorization or request here. Authorization is required before services - payments can be denied by EMPLOYER if client does not provide information before session.

Additional Comments

How did you learn about us? If you were referred please tell us by who or what. (Shhh! We are not allowed to tell anyone that you are a client or anything about you or your interests.)