RESTON PSYCHOLOGICAL CENTER P.C
1800 Town Center Drive, Suite 411
Reston Virginia 20190
703-437-3236

REGISTRATION FORM

Today’s Date _____/_____/_____

PATIENT INFORMATION

Patient’s Last Name

First

Middle

q Mr. q Mrs

q Miss q Ms.

Marital Status (Circle One)

Single / Mar / Div / Sep /

Street Address

City

State

Zip Code

Home Phone No ( ) -

Work Phone No ( ) -

Cell Phone No.

Birth Date

Age

Sex q M q F

Therapist Name

Social Security Number

Employer

Referred to Center by (Please check boxes that apply)

q Dr.

q Insurance

q Family

q Friend

q Close to Home/Work

q Yellow Pages

Other:

FINANCIALLY RESPONSIBLE PARTY

Person Responsible for Bill

Relationship to Patient (Check One)

Birth Date / /

qSelf qParent qOther

SS# - -

Street Address

City

State Zip

Home Phone ( ) -

Work Phone ( ) -

Cell Phone ( ) -

Person Responsible for Bill

Relationship to Patient (Check One)

Birth Date / /

qSelf qParent qOther

SS# - -

Person Responsible for Bill

Relationship to Patient (Circle One)

Birth Date

qSelf qParent qOther

Street Address

City

State Zip

Home Phone

Work Phone

Cell Phone

INSURANCE INFORMATION

(please give your insurance card to the receptionist)

Please indicate Primary Insurance

Subscriber’s Name

Subscriber’s ID/SS #

Group #

Birth Date

Employer

/ /

Patient’s Relationship to Subscriber

q Self

q Spouse

q Child

q Other

Name of Secondary Insurance (if applicable)

Subscriber’s Name

Group #

Policy #

Patient’s Relationship to Subscriber

q Self

q Spouse

q Child

q Other

X

PATIENT/GUARDIAN SIGNATURE

DATE