Client Information Form

CLIENT INFORMATION FORM



CONFIDENTIAL: FOR PROFESSIONAL USE ONLY

Client Name*



Birth Date*













Briefly describe your current concerns.


Previous Marriage/s?
Yes No 




$



Emergency contact











Previous Counseling or Psychological Care?
 Yes No

Therapist's Name










Your Physician's Name










 
Any Present Physical Complaints?
 Yes No

Are suffering from any major illnesses (surgery, handicaps, etc.)?
 Yes No

Are you taking any medication, drugs, or alcohol?
 Yes No

Spouse's Information

Name









Previous Marriage/s? - SP
 Yes No

Children's Information






 

I understand that I am responsible for payment at the time services are rendered (unless insurance payments are authorized payable directly to consultant/insurance services). I agree that any assistance for reimbursement from insurance does not absolve my full responsibility for payment. Furthermore, I will reschedule or cancel at least 24 hours prior to any scheduled appointment; and, if I fail to do so, I understand that I will be charged for said appointment.

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Date*