Client Information Form

Client Information Form
Client Name*

First NameLast Name
Does the client have a guardian?*

Yes--Guardian of the PersonYes--Guardian of the EstateYes--Guardian of the Estate AND PersonNo
Please list all family member names and relationships to the client*
Is the client a minor?*

YesNo
If the client is a minor--who has custody of the child?*
If the client is a minor--who is responsible for payment?*
If parents are divorced--is there a court agreement in place that may affect treatment?*

No divorceDivorced, but no court order that would affect treatmentDivorced with a court order that includes medical expenses and other items that would affect treatment
Have either parents' rights been terminated by the courts?*

NoYes
If there is a court order from the divorce that would affect treatment please get us a copy. If any parental rights have been revoked we need a copy of the court paperwork.
Parent/Guardian 1*

First NameLast Name
Parent/Guardian 1 relationship*
Parent/Guardian 1 address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 phone*

Area CodePhone Number
Parent/Guardian 2

First NameLast Name
Parent/Guardian 2 Relationship
Parent/Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Phone

Area CodePhone Number
Is there anything additional around family dynamics that would be helpful for us to know?
Client or Parent/Guardian Signature

Clear
Should be Empty: