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Client Name:_____________________________________Today’s Date:____________

Name of Guardian(s) (if client is a minor):_____________________________________

Address:_______________________________________________________________

City, State, Zip:__________________________________________________________

Gender:__________ DOB:____________ Age:_______  SSN:____________________

Relationship Status:    single    married    domestic partner    separated    divorced     widowed 

Occupation/Work Emphasis:_______________________________________________

Home Phone:___________________________ Okay to contact you there?_________
                                                                    Okay to leave a message?__________

Work Phone:____________________________ Okay to contact you there?________
                                                                     Okay to leave a message?_________

Cell Phone:_____________________________ Okay to contact you there?_________
                                                                     Okay to leave a message?_________

Referred By:_____________________________________________________________

Emergency Contact Name:___________________________ Phone:________________

Relationship to you:_____________Okay to contact in the event of an emergency?___

Please list other people living in your household and their relationship to you: 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Primary Insurance Information:

Insured Name:__________________________________________________________

Insured DOB:______________________ Insured SSN:_________________________

Insured Employer:_______________________________________________________

Payer/Health Plan:_______________________________________________________

Your Relationship to Insured:     self     spouse     dependent

Member Number:___________________ Policy/Group Number:___________________

Secondary Insurance Information:

Insured Name:__________________________________________________________

Insured DOB:______________________ Insured SSN:__________________________

Insured Employer:________________________________________________________

Payer/Health Plan:_______________________________________________________

Your Relationship to Insured:     self     spouse     dependent

Member Number:___________________ Policy/Group Number:___________________

Please present insurance card(s) to me, so that I can make a copy.

Please describe your reason(s) for seeking treatment at this time. If there is a particular event that triggered your decision to seek treatment now, please list the event:___________________________________ 

_____________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life:
 

.	No Effect	Little Effect	Some Effect	Much Effect	Significant Effect	Not Applicable
Relationship	.	.	.	.	.	.
Family	.	.	.	.	.	.
Job/School	.	.	.	.	.	.
Friendships	.	.	.	.	.	.
Finances	.	.	.	.	.	.
Physical Health	.	.	.	.	.	.
Anxiety Level	.	.	.	.	.	.
Mood	.	.	.	.	.	.
Eating Habits	.	.	.	.	.	.
Sleeping Habits	.	.	.	.	.	.
Alcohol/Drug Use	..	.	.	.	.	.
Sexual Functioning	..	.	.	.	.	.
Ability to Control Anger	..	.	.	.	.	.

What result(s) do you expect from treatment: ________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________