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Client Name
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First
Last
Preferred Name:
Date of Birth
*
Month
Day
Year
Age
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11
to
120
.
Gender
*
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Address
*
Street Address
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Email Address
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Occupation
Employer/School
Referred By
If the client is a minor, please provide the name/address/phone of a parent or guardian below.
Is the client under 18 years old?
*
Yes
No
Name
*
Relationship to Client
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Hawaii
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Northern Mariana Islands
Ohio
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Puerto Rico
Rhode Island
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Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Client Phone Contact Information
*
Phone Type
Phone Number
OK to Leave a Message?
Name of financially responsible party
*
Responsible Party Phone Number
*
Family Members
Name
Age
Relation
Please list the name, ages, and relation to you of each person living in the household.
Medical History
Have you experienced any major illnesses, operations, injuries, or hospitalizations?
*
Yes
No
Details
Please describe any medications you are currently taking that address mental health issues
Name of Medication
Dosage
Prescriber
Please describe your reason for seeking counseling services
What do you hope to accomplish in our work together?
Have you received counseling/therapy previously?
*
Yes
No
When did you previously receive counseling?
With whom did you previously receive counseling?
What were your previous diagnoses?
*
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