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Scottsdale Psychological Associates 11000 N. Scottsdale Road, Suite 163 Scottsdale, Arizona 85254 Patient InformationName: ___________________________________________________________________________ Address: ________________________________________________________________________ City: __________________________________ State:______________ Zip: ______________ Phone: (H) ______________________ (W) ____________________ (Cell)___________________ Age: _____________ Marital Status: _______________ Birthdate: ___________________ __ Employed __ Full-Time Student Social Security Number: _________________ Sex: _Male _Female Highest Level of School: ________________ If Child: Fathers Name: ________________________ Phone: (W) ________________ (Cell) _______________ Mothers Name: ________________________ Phone: (W) ________________ (Cell) _______________ If divorced who has power of medical decision making? __ Mother __ Father __ Joint Name of person completing paperwork and relation: __________________ Referral Source: ________________________________________________________________ Primary Care Physician:_____________________________________ Phone: _____________ In case of emergency please notify: Name: ______________________________________ Phone: _____________________________________ Emplyer Information: (Father and Mother if minor) Primary Insured: Employer Name: _____________________________________________ Employer Address: __________________________________________ Spouse: Employer Name: _____________________________________________ Employer Address: __________________________________________ Insurance Information: Insurance Company Name: _________________________________________________________ Social Security Number of policy holder: ________________________________________ Member ID Number: _________________________________________ Group Number:________ Is Medicare your __ Primary Insurance __ Secondary Insurance __ I do not have Medicare