Diana Seeb, Ph.D.
 

Clinical Psychologist PSY6773
                                 
                   

        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:________


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EMPLOYER:____________________________________________________________________

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Spouse's Employer:__________________________________________


Number & Ages of Children:_________________________________________


TELEPHONE: (Home) _________________(Cell) ____________________

(Work) ____________(Email)_______________________________________


EMERGENCY CONTACT:____________________________________________


INSURANCE: (Primary)_______________________________________

Policy #:_______________________________________

Group #________________________________________


INSURANCE(Secondary)___________________________________________________________

Policy#:__________________________________________________________________________

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CO-PAY:____________________


PRIOR AUTHORIZATION # (if applicable)______________________________

REFERRED BY:___________________________________________