JENNIFER L. BATTS, MS
Psychotherapy

5410 California Ave SW, Suite 201	Phone 206-271-9280	
Seattle, WA  98136	Fax 206-763-3087	
Website www.batts.org	Email Jennifer@batts.org	

CLIENT REGISTRATION
PLEASE PRINT AND ANSWER ALL QUESTIONS

CLIENT INFORMATION
					                                              Marital Status  S    M    D    W

Patient __________________________________________________________________________   Female  Male
(Full Legal Name)        Last                                             First                              Middle Initial

Home Address____________________________________________________________________ Apt. # ___________

City_______________________ State___________ Zip__________________ Home Phone______________________

Date of Birth_______________________   Age_______________ Your Email: _______________________________

Social Security Number____________________________________ 

Employer ________________________________________________ Work Phone____________________________   

Spouse’s Name________________________________________  Daytime Phone ______________________________

Relative or Friend__________________________________________ Relationship___________________________   

Daytime Phone__________________

Referred to this office by ___________________________________________________________________________

How do you prefer appointment reminders?   

 Email or   Phone, if so, Is it ok to leave reminder on voicemail?  Yes  No

BILLING
Payment is due at time of service unless otherwise arranged. Cash, Check, Credit Card and PayPal payments are all accepted.

RELEASE	
ASSIGNMENT AND RELEASE:  I understand that it is my responsibility to know and understand my insurance policy and its benefits.  I understand that I am responsible to make payment at time of service. I understand I will be provided with information so that I may attempt to receive reimbursement from my insurance company. I am financially responsible for any balance due.

SIGNED:_________________________________________                  DATE:________________________