Client name:
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Age:
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Client date of birth:
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Gender:
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Last 4 digits of social security #:
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Education:
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Employer:
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Home street address:
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City:
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State:
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ZIP code:
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Phone:
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Text to:
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Email address:
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Client referred by:
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Appointment preference days and times:
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Emergency contact:
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Emergency contact phone:
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Presenting problems (include past/present alcohol, chemical or substance use/abuse/dependency):
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What you hope to achieve from therapy:
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Past/present medical care (specify major problems, accidents, hospitalizations and current medications, including psychiatric):
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Family history (chemical dependency, mental illness, violence, suicide):
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Client interests:
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If using Employee Assistance Program (EAP), authorization #:
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# of EAP sessions:
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ALL CLIENTS MUST COMPLETE THE FOLLOWING INSURANCE INFORMATION (including EAP clients)

Insurance policy holder name (if different than above):
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Policy holder's date of birth:
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Policy holder's SSN:
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Home street address:
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City:
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State:
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ZIP code:
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Phone:
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Email:
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Text to:
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Employer:
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Employer address:
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Insurance (Primary) Name of insurance company:
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Insurance ID number:
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Group #:
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Provider/Behavioral/Mental Health phone number:
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Insurance address:
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Deductible amount:
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How much is met?:
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Copay or coinsurance amount:
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Pre-authorization #:
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When complete, press the "Submit" button below. If you do not advance to the successful completion page, please scroll up and enter any fields which you may have omitted.