Center for 
Psychotherapy
Registration Form



Welcome to the registration page for the Dr. Richard Wall's Clinic. We hope you will find this page easy to use. Complete the information below and then simply click on the "submit" button at the bottom of the form. Having this information prior to your appointment will help to reduce unnecessary waiting and speed your visit with our staff. Thank you for your help.



Personal Information

Name  

SexMale Female 

Age

Birth-Date  

Address

City State  

Zip Code

Home Phone  

Work Phone

Occupation  

Social Security #

Name of Nearest Relative Not Living with You

Address  

City

State Zip Code

Phone

Who Referred You to This Office

Do You have a Primary Care Physician (Give Name)

May we communicate with your Physician?Yes No

Billing Information

Responsible Party Name

Address  

City

State Zip Code

Home Phone  

Work Phone

Social Security #  

Date of Birth

Relationship to Patient


Insurance Information
Insurance Company  

Group Number/Name

Policy #  

Name of Insured

Insured's Date of Birth  

Insured's SS#

Your relationship to Insured

Does your insurance require pre-certification review?Yes No

Is this a Worker's Compensation Claim Yes No

If Yes, Claim #  

Adjuster's Name

Adjuster's Phone  

Date of Injury

Employer at time of injury

 


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