Individual Client Information Questionnaire

Individual Client Information Questionnaire

Individual Client Information Questionnaire
Your cooperation in completing this questionnaire will be helpful in planning our services for you. Please answer each item carefully or ask your clinician for clarification if you do not understand an item.

Individual Client Information Questionnaire
Personal Information
Full Name:*

First NameLast Name
hidden_field_1
Date:

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone (Home):*
Format: (000) 000-0000.
Telephone (Work):*
Format: (000) 000-0000.
Email:*
Birth Date:*

MonthDayYear
SSN:*
Marital Status:*
Occupation:*
Education:*
Employer:*
Who suggested you contact us?*
Please briefly describe your reason for seeking Counseling/Therapy:

Individual Client Information Questionnaire
Primary Insurance Information
Insurance Company Name:*
ID Number:
Group Number:
Primary Policy Holder Information

If different from the patient
Policy Holder Name:

First NameLast Name
hidden_field_2
DOB:

MonthDayYear
SSN:
Relationship to patient:
Please type the "Other" option here:*
Current Address:

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
Secondary Insurance Information
Insurance Company Name:
hidden_field_3
ID Number:
Group Number:
Secondary Policy Holder Information

If different from the patient
Policy Holder Name:

First NameLast Name
DOB:

MonthDayYear
SSN:
Relationship to patient:
Please type the "Other" option here:
Current Address:

Street Address

Street Address Line 2

CityState

Zip Code

Individual Client Information Questionnaire
Spiritual History/Religious Affiliations Information
Present Affiliations:*
YesNo
Why?*
Why not?*

Individual Client Information Questionnaire
Work History Information
Occupation:*
How long have you been in your current position?*
Hobbies/Avocations:

Individual Client Information Questionnaire
Emergency Contact Information
Name:*
Phone:*
Format: (000) 000-0000.
Relationship to the client:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: