Client Demographic Sheet
Counseling Within Reach, PLLC
Client Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Relationship to Client
Emergency Contact's Phone Number
-
Area Code
Phone Number
Presenting Concerns
Briefly describe what brings you to therapy.
Availability for telehealth appointments
Mornings (start times 9-11am) Afternoons (start times 12-2pm)
Monday mornings
Monday afternoons
Tuesday mornings
Tuesday afternoons
Wednesday mornings
Wednesday afternoons
Thursday mornings
Thursday afternoons
Friday mornings
Friday afternoons
Insurance Type and Member ID (if applicable)
Preferred method of contact
Email
Phone (may leave a voicemail)
Phone (may not leave a voicemail)
Submit
Should be Empty: