Get Tx Wanda Johnson-roberts Client Information 2017-2026

Filling out the TX Wanda Johnson-Roberts Client Information form online is an essential process for individuals seeking mental health services. This guide provides clear and supportive instructions to help users complete the form accurately and efficiently, ensuring that all necessary information is gathered for the patient's care.

Follow the steps to complete the client information form online:

1. Click ‘Get Form’ button to access the client information form online and open it in the editing interface.
2. In the first section labeled 'PATIENT', enter the full name of the person receiving services. In the 'REFERRBY' field, provide the name of the individual or entity that referred you for services.
3. Fill in the 'MAILING ADDRESS' including street address, 'CITY', 'ST.' for state abbreviation, and 'ZIP' code. Enter the 'PHONE #' in the designated field, ensuring it is accurate for communication.
4. Complete the 'Date of Birth' section with the patient's birthdate, written in MM/DD/YYYY format.
5. In the 'EMPLOYER' field, write the name of the employer for the patient and provide the employer's 'Phone' number.
6. Enter the patient's 'SS#' (Social Security Number) in the respective field. Then, indicate 'MARITAL STATUS' by circling either 'MARRIED' or 'SINGLE'.
7. Provide 'SPOUSE OR GUARDIAN NAME' if applicable and their corresponding 'PHONE NUMBER' and 'EMPLOYER' information.
8. List the names and ages of any 'CHILDREN' in the relevant section.
9. Fill out the 'IN CASE OF EMERGENCY CONTACT' section with the contact's name, 'PHONE #' and 'RELATIONSHIP TO YOU'.
10. Indicate how you may be contacted, filling in 'Phone' and any alternate phone numbers. Specify if messages may be left.
11. Provide an email address and indicate if email communication is allowed.
12. Answer the question regarding previous mental health services and include the 'PREVIOUS THERAPIST/PRACTITIONER' name and their 'TELEPHONE NUMBER'.
13. Read and acknowledge the payment policy by signing in the 'Signature' area and recording the 'Date'.
14. Complete the 'Primary Insurance' section with the necessary details, including the name of the insured, date of birth, insurance company, identification number, and account number.
15. For direct payment assignment, complete the designated fields detailing patient and employer information, and provide necessary signatures.
16. Review all information provided for accuracy, make any necessary edits, and save your changes.
17. Finally, download, print, or share the completed form as necessary.

Ensure you have completed the TX Wanda Johnson-Roberts Client Information form online today for optimal processing of your mental health services.