Client Information Sheet

Client Name*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

I am completing this form on behalf of:*

MyselfMy minor child/adolescent for whom I am seeking individual/family therapy

Parent/Legal Guardian 1*

First NameMiddle NameLast Name

Primary Phone*

Other Phone

Please enter a valid phone number.

E-mail*

example@example.com

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Legal Guardian 2

First NameMiddle NameLast Name

Primary Phone

Please enter a valid phone number.

Other Phone

Please enter a valid phone number.

Email

example@example.com

Do all parents/legal guardians reside in the same household?

YesNo

Insurance Information

Insurance Provider*

Group Number *

Id Number*

Employer

Subscriber’s Relationship to Client*

SelfSpouse/PartnerParent/Guardian

Subscriber’s Date of Birth (if other than self)

Date

Full Name of Primary Policy Holder (if other than self)

First NameMiddle NameLast Name

Address of Primary Policy Holder (if other than self)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insurance Provider

Check here if you have a secondary insurance provider, including a supplemental Medicare plan

Insurance Carrier Name*

Group Number*

ID Number*

Employer

Subscriber’s Relationship to Client*

SelfSpouse/PartnerParent/Guardian

Subscriber’s Date of Birth (if other than self)

Date

Full Name of Primary Policy Holder (if other than self)

First NameMiddle NameLast Name

Address of Primary Policy Holder (if other than self)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

In case of emergency, therapist has permission to contact the following person:

Name*

First NameMiddle NameLast Name

Relationship to Client*

Phone Number 1*

Phone Number 2

Please enter a valid phone number.

If you are involved in a court proceeding and a request is made for information, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without either your written authorization or a court order. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

If you ask me to disclose parts of the Client Record to a third party to support a disability claim, a civil lawsuit, divorce, or similar legal or quasi-legal pursuit, I will strongly advise you against doing so because of the potential harm to our therapeutic relationship. If you plan to use my testimony or any part of the Clinical Record for an upcoming legal or quasi-legal pursuit, please inform me immediately as I will provide referrals to a clinician who will perform such an evaluation.

There are situations in which I am legally obligated to take actions. These occur when I believe that possible harm may come to you or others as a result of your actions. If this happens, I may have to reveal information about your treatment. I will make every effort to fully discuss it with you before taking any action and will limit my disclosure to what is necessary. Such situations include the following:

If I have reasonable cause to suspect current abuse or neglect of a child or a dependent adult or elder-abuse.
If you communicate a threat of physical violence against a reasonably identifiable third person and I judge that there is apparent intent and ability to carry out that threat in the foreseeable future, I may have to disclose information in order to take protective action. These actions may include notifying the potential victim (or, if the victim is a minor, his/her
parents) contacting the police, and/or seeking hospitalization for you.
If I receive a subpoena, summons, court order, or court-ordered warrant, or an administrative request from a government agency including civil or authorized investigative demand or similar process authorized by law, I may be compelled to yield information. Even in these cases, however, only the minimum amount of information needed to satisfy the demand.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.

I have read and accept the preceding statement.*

Yes

Signature