New Client Information Form

Clients Name

Address

Apt

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email Address

Spouses Name

Phone

ParentGuardians Name

Phone_2

Insurance Carrier

Subscriber

Insurance ID

Group

Phone_3

Insureds Employer

Secondary Insurance

Secondary ID

Group_2

Phone_4

Names ages relationships of family members living at home 1

Names ages relationships of family members living at home 2

Names ages relationships of family members living at home 3

Is client presently taking medication If so name and dosage

If yes Counselor name and when were they seen

May we have permission to speak with andor obtain records from past counselor

Is the Client presently suicidal or homicidal

What is your goal for counseling andor the reason you called Use back if needed 1

What is your goal for counseling andor the reason you called Use back if needed 2

What is your goal for counseling andor the reason you called Use back if needed 3

Text3

Date4_es_:signer:date

Date5_es_:signer:date

Date6_es_:signer:date

Signature1_es_:signer

Signature2_es_:signer

Text6

Date_es_:date

DOB_es_:date

DOB_2_es_:date

DOB_3_es_:date

DOB_4_es_:date