Client Information

Thank you for choosing us. Please take a moment to fill out this form.
Today’s Date
MM slash DD slash YYYY
Name of primary client (name of child if appropriate):
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of birth of primary client:
Age of primary client:
School of primary client (if child):
Grade:
Contact information for client or if client is a minor, for parent(s) or guardian(s):
Name
Email
Home Phone
Work Phone
Cell Phone
Name
Email
Home Phone
Work Phone
Cell Phone
Insurance Provider
How did you find out about our services?
Please briefly describe the concern you wish to address:
May we contact the referral source (if applicable) to indicate that you have initiated treatment?
- Yes
- No
Name of individual or group/institution
Contact Info (Phone/Email)
If you are here to address a family concern, please list the names and ages of other family members who may attend therapy and their relationship to the person listed above:
How would you like things to improve as a result of treatment?
Name of client or client’s guardian*
Signature of client or client’s guardian*
Email*
Therapist*
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Email
This field is for validation purposes and should be left unchanged.

Updated: 7/21/2022

Contact information for client or if client is a minor, for parent(s) or guardian(s):