Adult Client Form V2.0

Name*

First NameLast Name

Date Of Birth*

Date

Gender:

FemaleMaleNon-binaryI Prefer Not To Say

If you prefer pronouns:

She/HerHe/HimThey/ThemI Prefer Not To Say

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Home Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Spouse/Partner's Name

First NameLast Name

Spouse/Partner Age

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Area CodePhone Number

Place of Employment*

How Long Have You Been Employed There?

Have You Been To Counseling Previously?*

YesNo

If Yes, How Long?

Who lives in the home?*

Please list names, ages, general health and mental health concerns.

Are there any pets in the home? *

Please list names, ages and general health of your pets.

What Brings You To Counseling Today?*

Whom Can We Thank For Referring You?

Today's Date*

Date

Signature*

New Client Questionnaire