Name of Client ________________________________________________ Birth date ____/_____/_____

Name of Spouse (or Parents of minor) __________________________________________________________

Children’s Names and ages (or Siblings of minor) _________________________________________________

__________________________________________________________________________________________

Client’s Address _____________________________________________________________________________

Street City State Zip

Home phone _______________________________ Cell phone ____________________________

Occupation / Employer: ______________________________ Email address _________________________

Primary Care Physician:_______________________________ Referred by: __________________________

Reason(s) for referral: ________________________________________________________________________

__________________________________________________________________________________________

Medications currently being taken by the client on a daily basis:_______________________________________

__________________________________________________________________________________________

Prior mental health services—i.e., with whom / how long: ____________________________________________

__________________________________________________________________________________________

Information below is required only if an insurance company is to be billed:

Primary Insurance Company _______________________________ Phone Number ___________________

Name of Policy Holder _________________________ Policy Number _______________________________

Policy Holder SS Number _______ / _____ / _______ Employer/Group no. ___________________________

Have you contacted the insurance company and received an authorization number? Yes______ No______

Authorization number: ____________________________ No. of visits ________ Co-pay amt. ______________