Introduction

First name

Last name

Birthdate

Month

Day

Year

Today's Date

Month

Day

Year

Gender

Marital Status

Partner First Name (If applicable)

Partner Last Name (If applicable)

Email

Street Address

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Preferred Contact Method

School or Employer's Name

Select Payment Type

Name of Insurance Company (if applicable)

Insurance ID (if applicable)

Insurance Group Number (if applicable)

Who Referred You

Emergency Contact Full Name

Emergency Contact Phone Number

Co Pay / Session Fee is due at the BEGINNING of EACH APPOINTMENT.

Payment can be Cash, Check, or Credit Card and will be made to the Therapist or Office Manager Directly

WE DO NOT MAKE REMINDER CALLS BEFORE APPOINTMENTS

Adult Information Form

Fill in all applicable fields

Describe the problem that brought you here today

Please check all behaviors/symptoms that you consider problematic

If your issue(s) were not listed, please add them here

Are your problems affecting any of the following

Have you ever had thoughts, made statements, or attempted to hurt yourself? (Yes or No)

Yes

No

If you answered YES please describe

Have you ever had thoughts, made statements, or attempted to hurt someone else? (Yes or No)

Yes

No

If you answered YES please describe

Have you recently been physically hurt or threatened by someone else? (Yes or No)

Yes

No

If you answered YES please describe

Please Submit and then open the Family Relationship Form