Patient Name
Date of Birth
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Month
-
Day
Year
Date
Address
City/State
Zip Code
Phone (Home)
Phone (Work)
Policy holder name
SS#(of policy holder)
Date of Birth
/
Month
/
Day
Year
Date
Employer
School (if patient is a student)
Insurance Co.
Referral Source
Never Married
Never Married
Married
Divorced
Separated
Widowed
Other
Family Members - Name / Date of Birth / Relationship
What concern brings you to counseling?
What changes do you want to see as a result of counseling?
Signature of Client
Today's Date
/
Month
/
Day
Year
Date
Signature of Responsible Party of a Client who is a Minor
Client Last Name
Client First Name
Other Possible Names
Client Date of Birth
/
Month
/
Day
Year
Date
Client Phone
Home Address
City/State
Zip Code
Name of Client:
Date of Birth:
/
Month
/
Day
Year
Date
Signature of Client or Personal Representative:
Printed Name of Client or Personal Representative:
If Personal Representative, indicate relationship
Date:
/
Month
/
Day
Year
Date
The Individual refused to accept a copy of the Notice of Privacy Practices.
The Individual received a copy of the Notice of Privacy Practices but refused to sign an of Receipt.
Signature of the Provider Representative:
Printed Name of the Provider Representative:
Client Name:
Date of Birth:
/
Month
/
Day
Year
Date
Signature of Client:
Responsible Party of a Client who is a Minor:
Date:
/
Month
/
Day
Year
Date
Signature of Client
Date
/
Month
/
Day
Year
Date
Signature Responsible Party of a Client who is a Minor
Date
-
Month
-
Day
Year
Date
Client Name Last / First /Middle Initial
Other Possible Names
Date of Birth
/
Month
/
Day
Year
Date
Phone
Address
City/State
Zip Code
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