Many questions in this packet are directed towards "you". If the person completing this form is not the client, please answer all questions in regard to the client and their experiences.
By listing this emergency contact, you authorize Silver Linings Counseling to contact this designated person in the event of an emergency and/or when other safety concerns arise.
Member/Enrollee ID: * Subscriber Name: * Subscriber Date of Birth: Date*
Member/Enrollee ID: Subscriber Name: Subscriber Date of Birth: Date
If you would like your therapist / Silver Linings Counseling to obtain previous medical records from another therapist, please fill out a Release of Information form.