Client Registration

Name
Prefix First Middle Last Suffix
Today's Date
Date Format: MM slash DD slash YYYY
Date of Birth
Date Format: MM slash DD slash YYYY
Phone
Email
Gender / Identification
It is OK to communicate with me using the following:*
- Select All
- Mobile phone (including voice messages)
- Home phone (including voice messages)
- Text messages
- Video Conferencing
- Email
- Other apps or websites (e.g., Doxy.me, Signal, Zoom)
- U.S. Mail
- Fax
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Section Break

Primary Health Insurance Provider*
Which insurance do you have and what is your ID number and group number as shown on the card?
What is your relationship to the primary insured person?*
- I am the primary insured
- I am the spouse of the primary insured
- I am a child of the primary insured
Secondary Health Insurance Provider
Is there secondary insurance? If so, what is your ID number and group number as shown on the card?
What is your relationship to the secondary insured person?
- I am the primary insured
- I am the spouse of the primary insured
- I am a child of the primary insured
Emergency Contact Name
This is usually a friend or family member. Describe the relationship if you like. I would only contact this person in an emergency.
Emergency Contact Phone
Authorizations*
I agree.
By providing the information on this form, you agree to the following:

- I authorize my insurance carrier to exchange information required to process my claims.
- I understand that I am financially responsible for any balance after insurance.
- I agree to be contacted using the methods provided above unless I instruct Dr. Turnbull otherwise.
- I have reviewed online or have received copies or access to Dr. Turbull's Notice of Policies and Practices to Protect the Privacy of Your Protected Health Information; Confidentiality and It's Limits; and Client Services Agreement.

I am aware that I can ask questions at any time.
Name
This field is for validation purposes and should be left unchanged.

J. Gregory Turnbull, Psy.D., J.D.