MyLightProgram.com Admission Form

Patient Information

Patient Name:
Date of Birth:
Sex:
Marital Status:
Social Security:
Address:
City:

State:
Zip Code:
Country:
Cell Phone:
Home Phone:
Work Phone

Emergency Contact / Guardian Info

Emergency Contact Name & Relationship
Emergency Contact Phone#:
Is the Client a Minor?	Yes No
Name of Parent or Legal Guardian
Name & Address of Parent with Legal Custody (In Cases of Divorce)

Insurance Info

Type of Insurance:
Insurance Group#:
Name of Policy Subscriber:
Subscriber SS#:

Insurance ID#:
Provider Phone#
Subscriber Date of Birth:
Subscriber Address:

Medical Info

Psychiatric (Medical Doctor)
PCP Practice Name/Doctor :
Doctor's Phone#:
If So, what Facility?
Discharge Date:
Prescribed Medications:

Counselor:
Doctor's Address
Discharged from Inpatient Facility?	Yes No
CaseWorker Name/Phone#:
Diagnosis/Issues

Other

How did you find out about the Light Program?
Any Questions you might have:

All of our therapists are licensed professionals. If you have any questions for your therapist you may ask them at the appointment or call 888-686-7511 to speak with a staff member.

Once an appointment is scheduled for you we have a cancellation policy which requires 48 hours notice. Failure to give us 48 hours notice results in a late cancellation fee, unless the cancellation is due to an illness or emergency.

Patient Information

Emergency Contact / Guardian Info

Insurance Info

Medical Info

Other

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