Client Information Form

All fields must be completed before submitting.

Personal Information

Client Name: Date of Birth: / /

Parent(s)/Guardian(s):
Legal Conservatorship:
Proof of legal conservatorship will be required for an appointment
Examples: divorce decree, power of attorney

Address:

City: State: Zip Code:

Please provide at least one contact number:
Home Phone: Work Phone: Cell Phone:

E-mail address:

Occupation: School/Employer:

Insurance Information

Insured? Yes No

Insurance Company: Mental Health Phone Number:

ID Number: Policy Holder:

Group Number: SSN:

Insured's Employer:

Appointment

Reason for Therapy:

Preferred appointment date or time:

Referral Source: