Intake Information – Deirdre Haynes Counseling Services

Intake Information Form

This form is used to collect basic information about you and your insurance provider.

Step 1 of 2

Deirdre F. Haynes, Ed.S, NBCT, NCC, LPCS, GCDF
1030 St. Andrews Road, Suite A-1 Columbia, SC 29210
Phone: 803-790-2025 Fax: 803-790-7010
E-mail: dhaynes@dhaynestherapy.com
Website: http://dhaynestherapy.com
Licensed Professional Counselor (#5425), State of South Carolina
Intake Information:
Name
First Last
Email*
Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Information:
Name:
First Last
Gender/Race/Relationship Status:
DOB:
MM slash DD slash YYYY
SSN:
Insurance ID number:
Group Number:
Insured place of employment:
Name of insurance company:
Insurance Phone #:
Insurance Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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