This is not the current form
Primary Client is a Minor
The correct form can be found at
https://hipaa.jotform.com/242913843950158
My Therapist/Case Manager is:
*
Please Select
Claudia Alvarez, LPC Associate
Lori Cadwallader, LPC
Alondra Benitez, LCSW
Rebekah dePeo-Christner, LPC
Jacob Doering, LPC
Shaharzade Ebrahimi, LCSW
Marcos Gonzalez, LPC
Andrew Hunter, LPC
Sadaf Meckfessel, LPC
Cindy Jacobson, LPC
"Jake" Jacobson LCSW
Estefania Loredo, LPC Associate
Michelle Moore, LPC
Isabel Murray, Masters Intern
Sunnie Palmer, LCSW
Rebecca Torres-West, LPC
Tina Taylor, LPC
Brittany Zielinski, LPC
I don't know/None of the above
DATE OF 1ST SESSION
*
-
Month
-
Day
Year
Date
Information about the Youth
YOUTH LAST NAME
*
FIRST NAME
*
MIDDLE NAME
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
CURRENT OCCUPATION OR "STUDENT"
*
EMPLOYER OR NAME OF SCHOOL
*
INFORMATION ABOUT THE PARENT/GUARDIAN
PARENT NAME
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
PARENT HOME ADDRESS
*
Please provide a physical address, NOT an email
CITY
*
COUNTY
*
STATE
*
ZIP
*
PHONE
*
EMAIL:
*
example@example.com
IN CASE OF EMERGENCY CONTACT INFORMATION
Please choose someone who will NOT be participating in counseling
NAME
*
RELATIONSHIP TO CLIENT
*
PHONE (1)
*
PLEASE LIST ANY CURRENT MEDICATIONS OR MEDICAL CONDITIONS:
PLEASE BRIEFLY DESCRIBE THE REASON YOU ARE SEEKING COUNSELING:
*
WHO REFERRED YOU TO US?
NAME:
*
AGENCY:
*
CLIENT OR PARENT GUARDIAN SIGNATURE
*
DATE
*
/
Month
/
Day
Year
Date
Are there additional participants OR another parent/guardian?
Yes
No
ADDITIONAL COUNSELING PARTICIPANTS OR AUTHORIZING ADULTS
CLIENT #3 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Add Client #4?
Yes
CLIENT #4 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION/STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Add Client #5?
Yes
CLIENT #5 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Add Client #6?
Yes
CLIENT #6 NAME
*
First Name
Last Name
Date of Birth
*
AGE
*
SEX (Required for some 3rd Party Pay Sources):
Please Select
Female
Male
PREFERRED PRONOUNS:
Please Select
She/her
He/him
They/Them
Other
OCCUPATION /STUDENT
*
EMPLOYER/SCHOOL
*
RELATION TO YOUTH
*
Submit
Should be Empty: