Client Information Form

Client Intake Form
Client Intake Form-Online Counselling and Online Workshops

MANDY-LEIGH SAMARIA VAN ASWEGEN Bpsych (HONS)

Psychology - Registered Counsellor

Practice No.0962120

Registration No. PRC0039578

Consulting Hours:

Monday -Friday 10:00-15:00

www.thewellsamaria.co.za

Cellphone:076 104 1462

Email: info@thewellsamaria.co.za

Practice Address:

18 Genl Hertzog Boulevard, 21 Spruitrivier Estate, Wellington, 7654
Name and Surname

First NameLast Name
Date of Birth
Name by which client prefers to be called
ID Number
Home Language
Date of first consultation
Occupation
Cellular Number
Home Telephone Number
Work Telephone Number
Gender
Ethnicity
Name of Nearest Family/Friend

First NameLast Name
Family/ Friend Cellular Number
Relationship to client
Family/Friend Home Number
Family/Friend Address
Source of referral Name and Surname

First NameLast Name
Referral Telephone Number
Referral Email Address
Occupational TherapistSpeech TherapistPhysiotherapistPsychological TherapyOtherRehabilitation centre or counselling for substance usePsychiatric Centre
Medical Information
List any Medications the client takes on a regular basis and specify the condition:
Which parent has residency of the minor in the case of divorce?
YesNo
Another family or friend we can contact if needed

First NameLast Name
Family/ Friend Cellular Number
Relationship to client
Family/Friend Home Number
Family/Friend Address
Name and Surname of person responsible for account

First NameLast Name
Identity number person responsible for account
Residential address person responsible for account
Cellular Number person responsible for account
Home Telephone Number person responsible for account
Work Telephone Number person responsible for account
Postal Address person responsible for account
Medical Aid Name
Main Members Name
Medical Aid Option
Medical Aid Number
Postal Address of Member
Should be Empty:

Client Intake Form