Client Demographic Form

Thank you for providing us with your demographic details. This information allows us to ensure that our services are inclusive and tailored to meet the diverse needs of our clients. Your privacy is important to us, and the information you provide will be handled with care. Please have your ID and insurance card ready to give to the receptionist when you arrive.
Personal Information
Name

First NameLast Name
Date of Birth DOB

MonthDayYear
Date
Social Security Number SSN
Address
City
State
Zip
County of Residence
Email
example@example.com
Contact Information
Primary Phone Number:
Whose phone is this?
Is it ok to leave a message?

YesNo
Secondary Phone Number:
Whose phone it this?
Is it ok to leave a message?

YesNo
Insurance Information
Primary Insurance
ID Number
Group Number
Provider phone number on the back of the card:
Secondary Insurance
ID Number
Group Number
Provider phone number on the back of the card:
Additional Information
Marital Status

SingleMarriedSeperatedDivorcedPartnerWidowed
Sex

MaleFemaleOther
Gender Identity

FemaleMaleFemale-to-maleMale-to-femaleGenderqeerOtherDecline to answer
Sexual Orientation

Straight/HeterosexualLesbian, Gay, or HomosexualBisexual
Race

WhiteBlack/African AmericanNative Hawaiian or Pacific IslanderAmerican Indian or Alaska NativeDecline to answer
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoBoth Hispanic and Latino
Employment Status

Full-timePart-timeSelf-employedUnemployedRetiredActive MilitaryDisabled
Student Status

Full-timePart-timeNot a student
Service Request
Please select all the service(s) you are requesting. Please ask if you are unsure.

Residential SUD Womens's 3.5Intensive Outpatient 2.1Outpatient 1.02.1 Board and LodgingComprehensive AssessmentDiagnostic AssessmentMental Health Therapy
Third Party Contacts
If you would like us to involve any third-party contacts in your care, please provide their details below. Note that a Release of Information form may be required later to share relevant information.
Probation Officer
Lawyer
Referrals/Others
Should be Empty:

Personal Information

Contact Information

Insurance Information

Additional Information

Service Request

Third Party Contacts