Client Information Forms

Client Information Forms
Client's name: *

First Name Last Name
Current date:

Month Day Year
Date of birth: *

Month Day Year
Age:
Marital status: *
Gender: *
Address: *

Street Address

Street Address Line 2

City State

Zip Code

Contact info *

Check if messages may be left.

Home phone:

Cell phone:

Work phone:

Email: *
example@example.com
Emergency contact name and phone: *
Relationship to emergency contact: *
School: *
Current grade: *
School adjustment (academic and social):
Who referred you to us? *

Another counselor/therapist Insurance company Family member Friend Internet I don't know

Family Data

Please provide the names of your family members and other requested information. *

Name

Date of birth

Education level

Spouse/partner:

Child:

Child :

Child:

Please provide the names of your family members and other requested information. *

Name

Date of birth

Education level

Father:

Mother:

Sibling:

Medical History
Family physician: *
Date of last exam:

Month Day Year
Condition of health: *
Describe any medical problems:
Allergies:
Hospitalizations:
List past medications taken:
List current medications taken:

Employment
Employment status: *
Employer: *
Occupation: *
Spouse's employer:
Spouse's occupation:

Additional Information
Please give a brief description of the concerns you, your child, or your family are experiencing along with an estimate of how long you have had these concerns. *
Please list other counseling or treatment you have and/or your family has received in the past and approximate dates. *
What are the main objectives you want to accomplish through coming here? *
Who are your main supports? *

Family Friends Church Work Associations Spouse None

Health Insurance Information
Person responsible for payment of services: *

First Name Last Name
Select one: *

Please file claims for services through my health insurance company. I plan to pay for services without the use of health insurance.
Click the button below to take a photo of the FRONT of your health insurance card. *
Click the button below to take a photo of the BACK of your health insurance card. *
Please check the box and sign below to indicate that you have read and understand the following policy statement. *

Your insurance plan is a contract between you and your carrier, and we are not a party to that contract. While filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date services are rendered. Our office will file with your insurance company as services are rendered, and if your insurance carrier fails to respond to the initial claim, we will resubmit your claim one additional time to attempt to recover their payment. If your insurance carrier fails to pay the second submission, you will be responsible for the entire balance on your account.
Type your signature: *
Relationship to policy holder: *
Policy holder name: *

First Name Last Name
Policy holder address (if different from patient):

Street Address

Street Address Line 2

City State

Zip Code
Policy holder date of birth: *

Month Day Year
Policy holder gender: *
ID number on insurance card: *
Insurance company: *
Is there another health benefit plan? If so, please specify below.

Client Information Forms

Family Data

Medical History

Employment

Additional Information

Symptom Checklist

Health Insurance Information