Non-Medicare New Client Paperwork Form 1

Instructions: Please answer the following questions about the client(s). Note: If you are completing this for a child or adolescent client, please answer each question in regard to the child, not to yourself. Thank you.

I. Identifying Information

Client's First Name(Required)

Client's Last Name(Required)

Today's Date(Required)

Date of Birth(Required)

Marital Status(Required)

Occupation(Required)

Please note phone numbers and email addresses where we may contact you and leave a message:

Home Phone #(Required)

Cell Phone #(Required)

Email Address(Required)

Person Completing this Form:

Person at school who referred me:

II. Reason for coming to therapy at this time:

Please describe.(Required)

III. Current Concerns:

(please mark any you are experiencing)

IV. Client’s Family History

Quality of relationship

Client's Age at the Death

Quality of the relationship

Client's Age at the Death

Quality of relationship

Client's Age at Death

Please list step-parents and other parental figures

If not always raised by parents, who provided care and when?

Names and ages of client’s siblings

Name and ages of client's children

Family history of emotional or behavioral concerns

Other family information

V. Client's Education

School's Phone Number

Current Grade or Level

Recent Grades/Performance

Special Services Received at School

Behavior Problems at School

Extra-curricular Involvement

Educational Level Obtained

Current Employer and Position

Length of Current Employment

VI. Client’s Medical History

Please list any major illnesses and physical disabilities(Required)

Date of last physical exam(Required)

Please provide the name of the professional and approximate dates of treatment:(Required)

Please list any previously diagnosed mental health conditions(Required)

List current medications(Required)

VII. In Case of an Emergency

Please let us know who we can call in case of an emergency.