Teletherapy Patient Identity Verification Checklist

Teletherapy Patient Identity Verification Checklist
Please complete this checklist to verify the patient's identity before starting the remote teletherapy session. All fields are required to ensure accurate verification.
Patient's Full Name
First NameLast Name
Preferred Name (if different)
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Scheduled Teletherapy Appointment Date and Time
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Last 4 digits of a government-issued ID (optional, for additional verification)
Please confirm one detail previously provided to our office (e.g., emergency contact's first name, insurance provider, or other non-sensitive info)
Staff Notes (for verification steps taken)
Should be Empty: