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Client Information Form

Your Information

First Name*(Required)

Last Name(Required)

Date of Birth(Required)

Month

Day

Year

Social Security Number(Required)

Drivers License Number(Required)

Or Passport number

State(Required)

State

Address(Required)

Street Address City State ZIP Code

Cellphone(Required)

Preferred email address(Required)

Office phone

Male/Female?(Required)

Were you referred by anyone?

Yes

No

Please enter the info of referral

Phone

Address

Street Address City State

Reason for scheduling your appointment(Required)

Briefly Describe your current concerns

Years at Current Occupation(Required)

Client's Occupation(Required)

Highest Education Completed

Family Annual Gross Income

Client Religious Preference

Other religious preference(Required)

Other

Marital Status

Marital Status

Previous Marriages

Yes

No

How Many?

1

2

3

4

5

Name

Age

Name

Age

Name

Age

Name

Age

Name

Age

Spouse's Information

Spouse's Information

Last Name

Occupation

Education

Religious Preference

Other

Children's Information

Do you have any children?(Required)

Yes

No

How Many?(Required)

1

2

3

4

5

Name(Required)

Age(Required)

Name(Required)

Age(Required)

Name(Required)

Age(Required)

Name(Required)

Age(Required)

Name(Required)

Age(Required)

Emergency Contact

Emergency Contact(Required)

Last Name(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Please select your insurance provider

Please select your insurance provider

Previous Counseling or psychological care?

Previous Counseling or psychological care?

Yes

No

Therapist's Information

Last Name

Physican's Information

Last Name

Medical

Any present physical complaints?

Yes

No

Are you suffering from any major illnesses (surgery, handicap, etc)

Yes

No

Are you taking any medication, drugs, or alcohol

Yes

No

*Required fields.

I value your privacy and do not sell or share your information.

"I understand that I am responsible for payment at the time services are rendered (unless insurance payments are authorized payable directly to provider for insurance services). I agree that any assistance for reimbursement from insurance does not absolve my full responsibility for payment."

Consent(Required)

By my signature, I am agreeing to the following statement. "I understand that I am responsible for payment at the time services are rendered (unless insurance payments are authorized payable directly to provider for insurance services). I agree to assist in recovery of insurance payments if needed. Non-payment from the Insurance Carrier does not absolve my full responsibility for payment of account balance."

Client Name(Required)

First Last

Client Signature(Required)

Date Signed

MM slash DD slash YYYY

I agree to the above statement*

I agree to the above statement

Comments

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CONTACT ME

JOYCE KAY HAMILTON, MLA/LPC
LICENSED COUNSELOR

214.823.2861 (OFFICE)
214.826.5863 (FAX)
EMAILME@JOYCEKAYHAMILTON.COM

MY LOCATION

5906 Llano Avenue
Dallas, Texas 75206

Off lower Greeneville Ave - S. of Mockingbird Ln & N. of Ross Ave

View Map & Get Directions >>

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Joyce Kay Hamilton, MLA/LPC