Please print and fill out form before your first appointment. If you are having a virtual appointment, please send me your completed and signed forms beforehand to my email address janinedebacker@msn.com
JKD Counseling, LLC
Janine DeBacker, MA, LMHC, # LH 60640839
601 Main Street, Suite 300 ● Vancouver, WA 98660
Phone 971.222.6924 ● Fax 360.695.1393
Client Information
Name_____________________________________ Date of Birth__/___/_____
Address______________________________________________________
street city state zip
Phone: ( ____)___________________ Sex: ( ) Male ( ) Female ( ) Other
Client Status: ( ) Single ( )Married ( ) Other
Emergency Contact ___________________________ Phone _________________ Relationship _________
Is Client’s condition is related to: ( )Employment ( )Auto Accident ( ) Other Accident
Relationship to Insured: ( ) Self ( ) Spouse ( ) Child ( )Other
Insured’s Information same as above (skip to Policy Information)
Name _____________________________________Date of Birth__/___/____
Address______________________________________________________
street city state zip
Phone: (__)___________ Sex: ( ) Male ( ) Female ( ) Other
Policy Information
Insured’s ID Number_________________________ Insured Policy Group or FECA number____________
Employer’s Name or School Name _________________________________________________________
Insurance Plan Name or Program Name_________________________
Is there another Health Benefit Plan? ( ) Yes ( ) No
Other Insured’s Name________________________________________________________________
Other Insured’s Policy or Group Number________________________________________________
Other insured’s Date of Birth ___/__/____Sex: ( ) Male ( ) Female
Employer’s Name or School Name_____________________________________________________
Insurance Plan Name or Program Name_________________________________________________
Authorization for release of information:
I authorize the release of any medical or other information necessary to process this claim. I also request
payment of government benefits either to myself or to the party who accepts assignment.
Signature________________________________________________ Date___/___/_______
Authorization for payment of medical benefits:
I authorize payment of medical benefits to JKD Counseling, LLC (Janine DeBacker, MA, LMHC).
Signature________________________________________________ Date ___/___/_______
Janine DeBacker 