Patient info Comisar Counseling

Patient Name
Date of Birth

MonthDayYear
Date
Address
City/State
Zip Code
Phone (Home)
Phone (Work)
Policy holder name
SS#(of policy holder)
Date of Birth

MonthDayYear
Date
Employer
School (if patient is a student)
Insurance Co.
Referral Source
Never MarriedMarriedDivorcedSeparatedWidowedOther
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

MonthDayYear
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

MonthDayYear
Date
Client Phone
Home Address
City/State
Zip Code
Name of Client:
Date of Birth:

MonthDayYear
Date
Signature of Client or Personal Representative:
Printed Name of Client or Personal Representative:
If Personal Representative, indicate relationship
Date:

MonthDayYear
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:

MonthDayYear
Date
Signature of Client:
Responsible Party of a Client who is a Minor:
Date:

MonthDayYear
Date
Signature of Client
Date

MonthDayYear
Date
Signature Responsible Party of a Client who is a Minor
Date

MonthDayYear
Date
Client Name Last / First /Middle Initial
Other Possible Names
Date of Birth

MonthDayYear
Date
Phone
Address
City/State
Zip Code
Should be Empty: