Diana Seeb, Ph.D.
 

Clinical Psychologist PSY6773

25255 Cabot Rd. Suite 211  Laguna Hills, CA 92653
                                  (949) 842-4420 
                     (This location closed to new patients)

        41750 Rancho Las Palmas Drive Suite K-1 Rancho Mirage, CA 92270
                                           (760) 660-4809

                14080 Palm Dr. Suite D  Desert Hot Springs, CA 92240
                                                   (760) 660-4809

                                                   
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 PATIENT INFORMATION


PATIENT NAME:____________________________________DATE:___________

SSN:________________________________DL#__________________________

DATE OF BIRTH:_________AGE:_____MARITAL STATUS:   S   M  W  D     GENDER:  M    F    DESCRIPTION:  Hgt:______Wgt:______Hair Color:________

HOME ADDRESS:__________________________________________________

EMPLOYER:____________________________________________________________________

Position:_______________________________________________________________________

Spouse/Significant Other Name:_____________________________________

Spouse's Employer:__________________________________________

Number & Ages of Children:_________________________________________


TELEPHONE:_________________(Home) _________________(Cell) Text:  Y  N

______________________________(Work) _________________________________(Email)

EMERGENCY CONTACT:____________________________________________


INSURANCE: (Primary)_______________________________________

Policy #:_______________________________________

Group #_____________________________________________________


INSURANCE(Secondary)___________________________________________________________

Policy#:__________________________________________________________________________

Group #:______________________________________________


CO-PAY:____________________

PRIOR AUTHORIZATION # (if applicable)______________________________

REFERRED BY:___________________________________________