Date:______________
Name:__________________________
Address: _____________________________________Zipcode_________
Phone Numbers: Home _____________________ Work______________________
Social Security # _______________ Age ______ Date of Birth______________
Employer____________________________________________
Occupation (major if Student)___________________ Work ________________
Address___________________________________________________________
Person to Contact in Case of Emergency________________________________________________________
Address____________________________________________________________
Phone________________ Relationship________________________________________________________
Health Insurance
Company_______________________________________________________ Address_________________________________________________________
Phone _______________________
Policy # ______________________ Group#_______________________
Physical/Emotional Concerns (X if problem, ? if possible problem or you are unsure)
| _____ Heart Problems | _____ Stress |
| _____ High blood Pressure | _____ Anxiety |
| _____ Gastro-Intestinal (Stomach) Problems | _____ Depression |
| _____ Respiratory(Breathing) Problems | _____Mood Swings |
| _____ Sleep Problems | _____ Suicidal Feelings |
| _____ Eating Problem/Concern | _____ Past Suicide Attempt (s) |
| _____ Headaches | _____ Grief/Loss |
| _____ Drug/Alcohol Problem | _____ Sexual Abuse/Incest |
| _____ Other Health Problem (explain) _______________________________ |
_____ Other (explain) _______________________________ |
Do You Use Alcohol?
Yes No
If Yes, How Much and How Often___________________________________
Do You Use Non Prescription Medications or Illegal Drugs?
Yes No
If Yes, What type and How Often____________________________________
If taking prescription medication, what type (s) and what for?___________________
Have You Ever Had Counseling Before?
Yes No
If Yes, In what situation?______________________________________
Name and Address Of Counselor____________________________________
Appointment and Payment Policies
Sessions are 50 minutes in length. Payment or insurance co-payment is due at time of session. If unable to keep a scheduled appointment you must call to cancel 48 hours in advance, without this cancellation you are still responsible for payment in full. Insurance companies will not pay for missed/appointments. Your signature indicates that you have read and agree with the Client Information Form as well as with these terms, and represents your consent for release of information to your insurance company for billing/payment purposes.
Client______________________________________ Date _______________
