Intake Form - Dr. Spillman & Associates
In-person or Virtual Appointments
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Email *
Address *
Phone number *
Ok to send text messages to this number? *
Ok to leave a voicemail at this number? *
Gender *
Required
Marital Status *
How many children/dependents? *
Insurance Information - List Name of Insurance, ID on insurance card, and telephone number for Insurance company. *
Primary Care Physician Name and Phone number *
Please list ALL medications prescribed to you. *
Do we have permission to coordinate care with your Primary Care Physician or Psychiatrist? *
Do you give consent to be treated by one of our health care providers? *
You have been informed that our office functions under the ethical code of the Texas Behavioral Health Executive Council and the address and phone number are listed in the waiting room or may be found online. *
All records are kept for the legal limit and purged after the limit. Our disclosure of confidential material requires your written consent except where there is child/elder abuse, potential suicide or potential homicide or by court order. I acknowledge this notice. *
Sessions are 45 minutes long, they are scheduled in advance and absent a 24 hour notice, you are responsible for the late cancellation fee. Email over the weekend is insufficient notice of cancellation for Monday appointments, please call the office directly. I acknowledge and agree to this cancellation policy. *
All sessions are billed in the name of Counseling Institute of Irving or Craig W Spillman, Ph.D., P.C. I acknowledge this notice. *
I acknowledge that sessions that are court ordered, part of a lawsuit, disability claim, divorce proceeding, child custody case or any other legal proceeding that my therapist will NOT represent me in these endeavors without PRIOR knowledge and that insurance cannot be billed for these services. *
Please enter your full name below. I understand that by entering my name below and clicking the "Submit" button that I am electronically signing this document.
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