Chris Chance Ph.D.​

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  • Home
  • About
  • Contact
  • Location
  • Psychotherapy & Life Coaching
    • Forms, Notices, & Links
  • Workshops/Group Experiences
  • Quotes & Dedication
  • GRATITUDE/RESOURCES
Chris Chance, Ph.D.
P.O. Box 66  100 High Street, Exeter, NH  03833  (603) 580-1136  [email protected]

 
CLIENT INFORMATION
 
Last Name: ___________________________________________________    Suffix: _________
First Name: _____________________________________________________      MI:  ___________
(If under 18 years old) Name of Parent(s): _______________________________________________
Client’s DOB: _______________      Age: _______   SSN#: _________________________________
Mailing Address: ___________________________________________________________________
City: ________________________________________       State: __________      Zip: ___________
Home Phone: (      )_____________   Work: (      )______________ Cell: (      )___________________
Okay to leave message?  Y/ N          Okay to leave message?  Y/ N          Okay to leave message?  Y/ N
Email - best: ______________________________    additional:  _____________________________
                 
Name of Primary Care Physician (PCP): _________________________________________________
Phone Number of PCP: (      ) __________________________________________________________
 
Emergency Contact:   Name:___________________________________________________________                            Relationship: _______________________ Phone: (       ) __________________
 
INSURANCE INFORMATION
 
Insurance Company (and policy type: PPO? HMO?):________________________________________
ID #:  _______________________________________________    Group #:  ____________________
Claim Address: _____________________________________________________________________
                        _____________________________________________________________________
Phone numbers back of Card:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does your policy cover the following “mental and behavioral health” services at Dr. Chance’s current practice location? (Circle Y or N)
 “Initial Evaluation”?   Y  N  “Individual Psychotherapy”?  Y  N    “Family/Conjoint Therapy”?   Y  N               
Outpatient Mental Health Authorization Needed?: Y  N     Copay: ______ Deductible: ____________
Authorization # for initial sessions(s): ___________________________________________________
Expiration Date: ________      # of Visits: ________      Annual MAX # visits? __________
Is this a “parity” policy (i.e., no annual max for certain “bio-based” diagnoses)?   Y   N
 
Relationship to Policy Holder: Self _____  Spouse _____     Child _____  Other ______
Policy Holder’s Name: _______________________________________________________________
Policy Holder’s Address: _____________________________________________________________
                                         _____________________________________________________________
Policy Holder’s DOB:  __________________ SSN:________________________________________
 
Secondary Insurance Company (if applicable): ____________________________________________
ID #:  _______________________________________________    Group #:  ____________________
Claim Address: _____________________________________________________________________
Phone numbers: _____________________________________________________________________
__________________________________________________________________________________
                       
Outpatient Mental Health Authorization Needed?: Y  N      Copay: ______ Deductible: ____________
Authorization #: ______________________________________________ Expiration Date: ________
Relationship to Policy Holder: Self _____  Spouse _____     Child  _____  Other  _________________
Policy Holder’s Name: _______________________________________________________________
Policy Holder’s Address: _____________________________________________________________
Policy Holder’s DOB:  __________________ SSN:________________________________________
Copyright 2024, Chris Chance, Ph.D.