FLY Client Information Form

31 N. Lansdowne Ave, Suite 203, Lansdowne, PA 19050

(located inside The Historic Lansdowne Theater)

www.FLYCounseling.com

(Ph) 844.578.7713 (Fax) 844.567.4413
Client Information Form*
*Clients under the age of 18 need to complete this form with a parent or legal gaurdian.
Today's date:

MonthDayYear
A. Identification
Full Name

First NameLast Name
Date of birth:

MonthDayYear
Age
What gender do you identify with?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home/evening phone:

Area CodePhone Number
May we leave a message?
Cell Phone

Area CodePhone Number
May we leave a message?
May we send a text?

C. You Medical Care
Clinic/Doctor's Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

D. Are you currently employed?
Employer:
Job title and duties:
How long have you worked with this employer?
If not currently employed, please share the month and year of your last date of employment.
(i.e. 7/2018)
Will you be using insurance?
If so, which insurance from list of current ACCEPTED insurers will you be using?

E. Education and Training

F. Family History

G. Marital History

Rows	Divorced	Domestic Partner	Married	Never Married	Separated	Single	Widowed
Marital Status

Rows	Partner's Name	Partner's Age at Cohabitation	Your Age at Cohabitation	Your Age when separated/divorced/widowed
First
Second
Third

H. Children

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

J. Emergency Information

If some kind of emergency arises, whom should we call?
Full Name

First NameLast Name
Relationship to you
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Signature of client
*If client is under 18, Signature of parent or legal guardian
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Should be Empty: