Client Informed Consent

Client Intake Forms

Anchored in Hope Counseling Services LLC. 33 Beaver Drive, Suite L Dubois, PA 15801 (814) 299-7771
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Number

Area CodePhone Number
Leave a Message?

YesNo
Secondary Number

Area CodePhone Number
Leave a Message?

YesNo
Email
example@example.com
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
By listing this person, I authorize the release of necessary information listed person in the event of an emergency or the inability to contact me for scheduling or treatment purposes.
If Minor, Parent/Guardian

First NameLast Name
Phone Number

Area CodePhone Number
Referring Person or Physician

Insurance/Payment Information
Insurance Company
Policy Number
Group Number
Subscriber Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Secondary Insurance Company
Policy Number
By offering this information, I agree to allow this practice to release necessary information to the above insurance company and insurance subscriber to submit billing claims on my behalf.
Auto Pay Information
Name on Card

First NameLast Name
Card Number
Exp. Date
CVV

Family/Social History
Marital Status

SingleMarriedDivorced/SeparatedCohabitatingWidowed
If applicable, Partner Information

Who currently resides with you (adults and children)?

	Name	Relation	Sex	Age
1
2
3
4
5
6

Any Children that do not live with you?

	Name	Sex	Age
1
2
3
4

Tell us about your family:

	Name	Living?	Age	Deceased?	Cause?	Married?
Father
Mother
Sibling
Sibling
Sibling
Sibling

Describe Relationship with Father
Describe Relationship with Mother
Describe Relationship with Siblings
Family History of Mental Health Diagnosis?

NoOther