CLIENT DEMOGRAPHIC INFORMATION

__________________________      _____________________      ______                    __________

 Last Name                                            First Name                                 MI                            Sex

 _____________________________________ ____________ _______ ______________

Address                                                                                   City                             State                  Zip

 __________________________

Cell Phone

 A message may be left at (please check all that apply) _______ Cell   _____ Text

 _______________            _____________________

Date of Birth                        Marital Status

 _______________________________________________________

Employer/School Occupation

 __________________________________________________________________

Spouse’s Name OR if a Minor, Name of Parent or Guardian (Last, First, MI)

 ___________________________________________________

Spouse’s Employer or Minor Child’s Parent’s/Guardian’s Employer

 ___________________________________________                       ___________________

In Case of Emergency Contact: Telephone Number                           Relationship to Client

 INSURANCE INFORMATION

 ________________________________          ______________         _____________________

Name of Insurance Plan                                        I.D. Number                           Insurance Group #

____________________________________________________       ____________________      

Insurance Company Address (back of card)                                                Insurance Telephone #

 Name of Insurance Policy Holder (Guarantor/Person carrying plan):

____________________________________________                          ________

Last Name                              First Name                                                       Sex: M F

 _________________________________________________________________________

Address                                                                  City                                   State                  Zip

 ________________              _________________                     ________________________

 Cell Phone                                Date of Birth                                   Company Employer                                              

  MEDICAL INFORMATION

__________________________________                                   _____________________

Primary Care Physician                                                                         Physician Phone Number

 Current Medical Issues/Allergies:

Current Medications:

Reason for seeking counseling: