New Patient Request Form - Center for Family Guidance, PC

Welcome and Thank you for your interest in Center for Family Guidance, PC. Our intake department takes pride in their ability to personally match you up with the most appropriate clinician to meet your needs. Please use the preferred secure intake form below to avoid long hold times. A representative will contact you during regular business hours, Monday-Friday. You can also reach us by phone at 856-797-4700.

NOTE: If the patient is 18 or older, the patient will need to be the one to make their own appointment, unless verbal consent is given by the patient.

INSURANCES ACCEPTED: Aetna, AmeriHealth, AmeriHealth Administrators, Blue Cross Blue Shield, Cigna, Horizon Blue Cross Blue Shield, Independence Blue Cross Blue Shield, Keystone, Magellan, Medicare, Tricare, Quest, Qualcare and Tri-State.

If you are new to CFG, please review our Patient Information page.

Personal Information

Patient Name *

First

Last

Patient Legal Name

Name of Person requesting this appointment

Relationship to the patient

If patient is over 18 years old we are only able to speak with the patient unless patient consent is given.

Date of Birth *

Age *

Email *

Email okay to send notification

Okay to send notifications

Patient's preferred phone number *

Is this phone number:

Cell Phone
Home Phone

Preferred contact phone number - Send Notifications

Okay to send notifications

Second contact phone number

Is this phone number:

Cell Phone
Home Phone

Second contact phone number - Send Notifications

Okay to send notifications

Patient's Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Employer *

Reason for seeking treatment (include diagnosis if applicable) *

How did you hear about us?

How did you hear about us - Hospital

How did you hear about us - Other

If patient is a minor, does child reside with both custodial parents? *

Yes
No

Please state Custody Arrangement *

Please download and complete the Consent for Treatment of a Minor (pdf). The completed form can be faxed to 856-797-4775 or emailed to intake@cfgpc.com.

Insurance Information

Name of Insurance Company *

Address of Insurance Company *

Address Line 1

Address Line 2

City

State

Zip Code

Full Name of Policy Holder or Guarantor *

First

Last

Date of Birth of Policy Holder or Guarantor *

Policy Holder or Guarantor SS# *

Address of Policy Holder or Guarantor *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number of Policy Holder or Guarantor *

Policy Holder or Guarantor Employer *

Insurance Member ID # *

Group Number *

Insurance Phone Number *

Effective Date of Insurance *

Does the patient have secondary insurance? *

Yes
No

Secondary Insurance

Name of Insurance Company *

Address of Insurance Company *

Address Line 1

Address Line 2

City

State

Zip Code

Full Name of Policy Holder or Guarantor *

First

Last

Date of Birth of Policy Holder or Guarantor *

Policy Holder or Guarantor SS# *

Address of Policy Holder or Guarantor *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number of Policy Holder or Guarantor *

Policy Holder or Guarantor Employer *

Insurance Member ID # *

Group Number *

Insurance Phone Number *

Effective Date of Insurance *

Service Request

What services are you requesting? *

What is the best time to call you back to discuss your request? *

Between 8 am and 12 pm
Between 12 pm and 3 pm
Between 3 pm and 7 pm

Which office location do you prefer? *

Marlton Office
West Deptford Office
Westampton Office

What type of appointment would you prefer? *

In person office visits
Telehealth appointments through video conferencing
No preference

What is your physician preference? *

A female clinician
A male clinician
No preference

What is your appointment preference? *

Appointments in the morning
Appointments in the afternoon
No preference

Please submit your form and a Center for Family Guidance Intake Representative will call you back. Please submit only one request for treatment for each potential patient. Multiple request for the same potential patient will delay our response time. Thank you for your interest in Center for Family Guidance