Client First Name: *

Middle

Last Name: *

Birthdate: *

Age:

Gender:

Social Security#: *

Client Street Address: *

City: *

State: *

Zip Code: *

County of Residence: *

Phone (Primary): *

(Recommend Cell Phone to use with Text Reminders for Appointments)

Phone (Secondary):

(Skip if No Secondary Phone)

Phone (Other)

(Skip if No Other Phone)

Primary Client Preferred Email Address:

Is there a legal guardian(s) for the primary client? *

NO, Primary client is OVER 18 and DOES NOT not have a legal guardian.
YES, Primary client is UNDER 18 and has a legal guardian(s).
YES, Primary client is OVER 18 but DOES HAVE a legal guardian(s).

How many legal guardians are there for client?

One legal guardian.
Two legal guardians.

Legal Guardian (A) First Name:

Guardian (A) Last Name:

Guardian (A) Date of Birth

Guardian (A) Social Security#:

(Client’s Primary Insurance)

Guardian (A) Relationship:

Does Guardian (A) Live Full Time at the Same Address w/ Client?

Living w/ Primary Client FULL TIME
Living w/ Primary Client PART TIME
Other/NOT LIVING w/ Primary Client

Primary Guardian (A) Street Address:

Guardian (A) City:

Guardian (A) State:

Guardian (A) Zip Code:

Guardian (A) County:

Guardian (A) Phone:

Briefly Describe Guardian (A) Living Arrangement w/Client:

Legal Guardian (B) First Name:

Guardian (B) Last Name:

Guardian (B) Date of Birth

Guardian (B) Social Security#:

(Client’s Primary Insurance)

Guardian (B) Relationship:

Guardian (B) Living Arrangement w/ Primary Client?

Living w/ Primary Client FULL TIME
Living w/ Primary Client PART TIME
Other/NOT LIVING w/ Primary Client

Guardian (B) Street Address:

Guardian (B) City:

Guardian (B) State:

Guardian (B) Zip Code:

Guardian (B) County:

Guardian (B) Phone:

Briefly Describe Guardian (B) Living Arrangement w/Client:

Primary Client Employee Assistance Program (EAP) Information:

Does the Primary Client Have EAP Benefits for Services? *

YES, Primary Client DOES have EAP Benefits for Services
NO, Primary Client DOES NOT have EAP Benefits for Services

(Employee Assistance Benefits)

EAP Company Name:

EAP Phone Number:

EAP Authorization Number:

EAP Authorization Details:

Primary Health Information:

Does the Primary Client have a Primary Care Physician? *

Yes
No

Name of Primary Care Physician:

Physician Phone:

Physician Street Address:

City:

State:

Zip Code:

Does the primary client have any health/medical conditions? *

Yes, client has pre-existing health conditions
No, client does not have any pre-existing health conditions.

Briefly describe client’s health/medical conditions:

Is primary client taking any medications currently? *

Yes, client is currently prescribed medications.
No, client is not prescribed any medications.

Please list client’s current medications (Name, Dosage, Frequency):

Emergency Contact Information for Client:
Please list the name(s) of at least (1) family member, relative or other individual(s) that we can contact in case of an emergency.

Emergency (A) First Name: *

Emergency (A) Last Name: *

Emergency (A) Phone: *

Emergency (A) Relationship to Client: *

Emergency (B) First Name:

Emergency (B) Last Name:

Emergency (B) Phone:

Emergency (B) Relationship to Client:

Any Additional Comments:

(Optional)

Number

Alert!