Client Information Form
Please complete the following information to help us serve you better.
Client's Legal Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Preferred Name
Pronouns
Examples: she/her, he/him, they/them
Date of Birth
*
-
Month
-
Day
Year
Date
Legal Guardian's Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Legal Guardian's Relationship to Client
*
Examples: Mother, Father, CPS Caseworker, Step-Parent with Medical Rights
Client's or their Legal Guardian's Email
*
example@example.com
Address 1
*
Address 2
City / State
*
Zip Code
*
Primary Contact Phone
*
Please enter a valid phone number where you can be reached in order to set up services.
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Sex Assigned at Birth
*
Male
Female
Gender Identity
*
Please Select
Male
Female
Non-binary
Trans Woman
Trans Man
Prefer not to say
Other
Sexual Orientation
Please Select
Heterosexual/Straight
Lesbian or Gay
Bisexual
Asexual
Pansexual
Prefer not to say
Other
Race (You May Mark More Than One)
*
White
Black or African American
Asian
Middle Eastern
Native American or Alaska Native
Native Hawaiian or Pacific Islander
Prefer not to say
Other
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Prefer not to say
Other
Languages Spoken
Marital Status
Please Select
Single
Married
Divorced
Widowed
Separated
Domestic Partnership
Other
Employment Status
Please Select
Employed Full-time
Employed Part-time
Unemployed
Student
Retired
Self-employed
Other
Religious Affiliation
Please Select
Christianity
Islam
Hinduism
Buddhism
Judaism
Wicca
No Affiliation
Prefer not to say
Other
Reason for Services
*
Please provide a brief description regarding what is happening or current stressors leading to seeking out therapy services at this time.
Other Significant Information
Please provide any additional information that you feel is important to share prior to meeting.
Questions
Are there any questions or concerns that you have regarding starting therapy services?
Submit
Should be Empty: