Patient Intake Form

Let's Get Started

Hello! Please complete the information below to get started with CMG Therapy. Please be sure to have your insurance card handy before starting this application. If you have any questions, email cmg@cmg-therapy.com.

First name

Last name

Email

Address

Birthday

Month

Day

Year

How would you like to pay for your sessions?

Insurance

Out of Pocket

If using insurance, what is the insurance provider's name? (for example: Aetna, Blue Cross Blue Shield, etc.)

Member ID

This may include letters and numbers. Please double check for accuracy.

Full and complete name of the primary on the insurance card

Date of Birth of the primary on the insurance card

Contact

Clinic Hours

Notice to Clients

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