Client Information Forms

Client Information Forms
Client's name:

First NameLast Name
Current date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of birth:

MonthDayYear
Age:
Marital status:
Gender:
Address:

Street Address

Street Address Line 2

CityState

Zip Code

Contact info

Rows		Check if messages may be left.
Home phone:
Cell phone:
Work phone:

Consent to Receive Text Messages

In accordance with the prevailing standards established to enhance transparency and trustworthiness in business text messaging and to explain the texting policy of Daybreak Counseling, Ed Wojniak, PhD, has implemented both a Privacy Policy and Terms and Conditions (T&Cs). So that you can make an informed decision about whether you agree to receive text messages from Daybreak Counseling, please review them here:

Daybreak Counseling's Privacy Policy and T&Cs.
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?

Other

Family Data

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

Rows	Name	Date of birth	Education level
Spouse/partner:
Child:
Child:
Child:
Child:
Child:
Child:
Child:
Child:

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

Rows	Name	Date of birth	Education level
Father:
Mother:
Sibling:
Sibling:
Sibling:
Sibling:
Sibling:
Sibling:
Sibling:

Medical History
Family physician:
Date of last exam:

MonthDayYear
2 digit month, 2 digit day, 4 digit 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?

Other

Health Insurance Information

If the patient is uninsured or does not plan to use her or his insurance benefits to pay for psychotherapy services, we can provide a Good Faith Estimate of the range of expected costs. Just ask and we will be happy to provide it.
Person responsible for payment of services:

First NameLast Name
Select one:
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 NameLast Name
Policy holder address (if different from patient):

Street Address

Street Address Line 2

CityState

Zip Code
Policy holder date of birth:

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

Rows	Never or hardly ever	Sometimes	Often	Always or almost always
Headaches
Faintness or dizziness
Chronic pain
Weakness, numbness or tingling in parts of your body
Difficulty making decisions
Worrying or stewing about things
Keyed up, restless or agitated
Easily fatigued
Irritable
Trouble remembering things
Easily distracted
Difficulty listening to others
Losing things
Behaving impulsively (without thinking)
Loss of sexual interest or pleasure
Poor appetite
No interest in things
Thinking about death or dying
Hopeless about the future
Sad or empty most of the day
Racing thoughts
Difficulty in falling asleep or staying asleep
Unusual periods of happiness
Involved in a task to the point of skipping meals, sleep or other important things
Doing risky or harmful things (for example, spending money too freely, abusing drugs or alcohol, engaging in casual sex, driving carelessly)
Feeling fine even when you get much less sleep than usual
Unable to get rid of bad thoughts or ideas
Bad dreams
Fearful
Heart pounding or racing
Avoiding certain things, places, or activities because they frighten you
Repetitive behaviors I have difficulty controlling

Client Information Forms

Family Data

Medical History

Employment

Additional Information

Symptom Checklist

Health Insurance Information