Today's Date:
*
/
Month
/
Day
Year
Date
Client's Full Name:
*
Client's Date of Birth:
*
/
Month
/
Day
Year
Date
Phone Number:
*
Email
example@example.com
SSN #
###-##-####
Gender
*
Male
Female
Is the client over 18 y/o:
*
YES
NO
Emergency Contact Name:
Emergency Contact Phone Number:
Emergency Contact Relationship
Client's Address:
Street Address
*
City,State,Zipcode:
*
If Patient is a Child Please Enter Parent/Guardian Name:
*
If not applicable enter N/A
Parent/Guardian Date of Birth:
/
Month
/
Day
Year
Date
Parent Guardian Phone number #:
Parent/Guardian Address,City,State,Zipcode:
Reason(s) for Referral (CHECK ALL THAT APPLY):
*
Depression/Anxiety
Post-partum Depression/Anxiety
Racial Related Trauma
Anger Management
PTSD
Behavioral Issues/ School Problems
Substance Abuse
Weight/Obesity
Medical Related Depression/Anxiety
Suicidal/Homicidal Ideations
Family Conflict
Grief/Loss
Infertility
Other
If Other is Selected Briefly Explain:
Current Medications :
Insurance/Billing Information:
Self-Pay
*
YES
NO
Insurance:
*
YES
NO
Medical Assistance:
*
YES
NO
Insurance Name:
*
If question is not applicable enter N/A
Insurance Policy Number:
*
If question is not applicable enter N/A
Insurance Group Number:
*
If question is not applicable enter N/A
Policy Holder Name and Date of Birth:
*
Medical Assistance Number:
*
If question is not applicable enter N/A
Attach any additional information:
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