Bring the following completed forms to your initial session:
- Client Information form
- Therapy Information and Agreement form
- CMS 1500 Insurance claim form (if you are planning to use insurance)
Couples: each individual in the couple must complete a separate Client Information Form.
CLIENT INFORMATION FORM
Name: Date of birth:
Address:
Phone (circle best number to call) Check if ok to leave messages
Home:
Cell:
Work:
Email:
Family information
Marital status (circle): single married divorced separated widowed
Spouse’s name: Date of birth:
Child’s name: Date of birth:
Child’s name: Date of birth:
Child’s name: Date of birth:
Child’s name: Date of birth:
Number of previous marriages, if any:
Former Spouse’s name: Date of birth:
Former Spouse’s name: Date of birth:
Medical
Name of medical insurance plan, if any:
How long ago was your last visit to a doctor? Last complete physical exam?
Do you have a primary care physician?
What medications do you currently take?
Employment information
Currently employed? (circle) YES NO Employer’s name:
Job title: Years at this job:
Education
Degree: School: Graduation date:
__________________ _______________________________ ____________
__________________ _______________________________ ____________
__________________ _______________________________ ____________
Previous Counseling
Name of counselor: Duration of therapy:
Name of counselor: Duration of therapy:
Name of counselor: Duration of therapy:
