Contact Information

First Name:
Last name
Street Address:
City, State, ZIP
Home Phone:
Cell Phone
Work Phone:
Best time to call
Email address:
IM address
Emergency Contact:
Address and Phone

Insurance and Referral Information

Insurance Company:
Address and Phone
Policy Number:
Client ID Number
Group Number:
Authorization Number
Who referred you:

Personal Details

Social Security Number:
Date of Birth
Marital status:
Sexual Orientation
Ethnicity:
Religion
Current Employer:
Current Position
Past Employer:
Past Position
Highest Education:
School Attended
Military (active/retired):
Branch
Which parents are living:
Birth order
How many brothers:
How many sisters

What are your hobbies/interests:

Where do your family members live:

Mental Health Information

Ever attended Therapy:
What kind of therapy
Therapist Name:
Address and Phone
When did you attend therapy:
Was therapy helpful

Family History Health Concerns:(mood disorders, alcoholism, substance abuse, etc)

List Current and past prescription medications:

Have you ever been hospitalized for a mental heath situation (Describe):