285 E. Main St Somerville, NJ 08876
contact@ilcnj.com
(908) 707-0212
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908-707-0212 contact@ilcnj.com

Client Registration Form

Home Client Registration Form

CLIENT REGISTRATION FORM

Please complete all sections. The client, if an adult, is regarded as being responsible for all charges generated.

Last name:
First name:
Date of birth:
Sex:
Marital status:
Street Address:
City:
State:
Zip:
Home phone:
Cell phone:
Work phone:
Email:

Emergency Contact

Last name:
First name:
Relationship to client:
Phone:
Alt phone:
Street address:

INSURANCE INFORMATION

Person responsible for account

Last name:
First name:
Date of birth:
Relationship to client:
Name of insured on card:
Address (if different from above):
City:
State:
Zip:
Insurance company:
Phone:
Subscriber number:
Group number:

SECONDARY INSURANCE

Insurance company:
Phone:
Subscriber number:
Group number:

Responsible party agrees to fill out a new form when any of the above information changes.
Wrong information may result in incorrect filing and subsequent charges.

ASSIGNMENT AND RELEASE

I, the undersigned, hereby authorize and direct my insurance carrier to pay directly to Inner Light Counseling all insurance benefits, if any due to me under my insurance plan. I further agree to pay the balance of the charges not paid by my insurance. Any balance that is not paid within 45 days will also be my responsibility and will be charged to the credit card on file. I hereby authorize the release of any information necessary to secure payment of benefits. I also authorize the use of this signature on all insurance submissions. If the client is a minor, I as the legal guardian give consent for treatment for this and future services rendered. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Responsible Person/Client Signature:
Date: