Client Intake Forms
Please complete our intake form so we can prepare for your session. If you have any questions contact glen@familyaddictioncounseling.com or call/txt (808) 494-6066.
Client Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender *
Marital Status *
Address *
Your answer
Cell Phone *
Your answer
Email
Your answer
Employer or School
Your answer
Emergency Contact *
Your answer
Emergency Contact Phone *
Your answer
Relationship to Emergency Contact *
Name of Psychiatrist or Primary Doctor
Your answer
Name of Insured (If diff than client)
Your answer
Insured Date of Birth (If different than client)
Your answer
Insured Relationship to Client *
Insurance Plan *
Insurance Policy Number *
Your answer
Insurance Group
Your answer
Social Security Number
Your answer
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