CLIENT REGISTRATION AND INTAKE INFORMATION

Geoff Bathje, PhD
CLIENT REGISTRATION AND INTAKE INFORMATION
Client Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender and Pronouns
Sexual Orientation
Race/Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
E-mail
example@example.com
Would you like to be informed of relevant events and trainings I facilitate? (about one email every 2 or 3 months at most; unsubscribe any time)
Referred by
Reason(s) for seeking therapy:
What is your preferred contact method regarding scheduling and appointments?
May I leave a voicemail?
May I send a text message?
May I contact you by email?
Whom may I contact in case of an emergency? (Name):
Address:
Phone:
Format: (000) 000-0000.
Relationship to Client:
Please list current and/or chronic health problems:
List current prescription medications, vitamins, supplements, and health aids you use/take: