Client History Form

Client History

41400 Dequindre Rd, Suite 110, Sterling Heights, MI 48314 • P 586-580-2975 • F 586-580-2954 • info@silverliningspllc.com • silverliningspllc.com
This form helps us better understand your background, current concerns, and goals for treatment. Your responses allow your clinician to prepare for your care and provide services that are individualized to your needs.
Client Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Preferred Name
Your relationship to the client
Your name
Please note: Unless otherwise stated, all questions are intended to be answered about the client. If you are completing this form on behalf of someone else, please answer from their perspective.
Client Identity
We ask this information to ensure accurate records and provide respectful, inclusive care.
Legal Gender
Gender Identity
Other Gender Identity
Pronouns
Race/Ethnicity
Other Pronouns
Other Race/Ethnicity
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Age
DOB
Contact Information
Home address

Street Address Line 2
Formatted Address
Phone number
Format: (000) 000-0000.
Email
Preferred method(s) of contact:
How did you hear about us?
Please let us know which one!
Emergency Contact
Name
Relationship to You
Phone Number
Format: (000) 000-0000.
We require at least one emergency contact for all clients. This information is only used if there is a concern for your safety or well-being, and a wellness check is deemed necessary.
Insurance Information
Will you be using health insurance for services?
Are you the subscriber?
Primary Insurance
Member ID
Group Number
Subscriber Name
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Formatted subscriber dob
Insurance Card Front

Cancelof
Insurance Card Back

Cancelof
Have secondary insurance? Email a copy of your insurance card to info@silverliningspllc.com.

Your Personal Story
What do you consider to be your strengths? List as many as you can!
Tell us about any supports or accommodations that would be helpful for you.
Do you have any preferred approaches to care?
Is there anything else important for us to know?
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Formatted Date Submitted
Client (or parent) ID

Cancelof
Should be Empty: