Date: ___________
Name: _________________________________________________
Name I like to be called: ____________________________
Address: ____________________________________________________ City:____________ State:_____ Zip: _________
Date of Birth: __________________________________________________
H. Phone: ( ) _______________________
Mo./Day/Yr. C. Phone: ( ) _______________________
Employer: _________________________________________________
W. Phone: ( ) _______________________
Email Address: ______________________________________________Referred By: __________________________________
Notify in Emergency: Name____________________________________ Phone: ______________________________________
Insurance Company: ________________________________________
Policy Number _______________________________
Address: __________________________________________________
Phone: ( ) _________________________________
Primary Physician: __________________________________________
Phone: ( ) _________________________________
Medications: _____________________________________________________________________________________________
Drug & Alcohol Use: _______________________________________________________________________________________
Counseling History: _______________________________________________________________________________________
________________________________________________________________________________________________________
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Other Pertinent Information: _________________________________________________________________________________
________________________________________________________________________________________________________
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I have received my packet of information with Consent for Treatment, including general office information, and Notice of Privacy/HIPAA statements. Should you have any questions about the above statements, please talk to Elaine before signing.
Reminder: Sessions are regularly $125 for 50 minutes, unless otherwise specified. I understand that if I do not keep a scheduled appointment,
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(Client Signature)
