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Patient Intake Form
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Patient Intake Form

Name: ___________________________________ SS#: _____________ Date of Birth: __________ Age: ______ Gender: Male Female Non-Binary Transgender Other:___________ Address: _________________________________________ City/State/Zip: ______________________ Employer/School: ______________________________________________________________________ Home Phone: ________________________ Cell: ______________________ Work: _________________ Where do you prefer to receive calls? __Home __Cell __Work Can I leave a message? __Yes __NoMay I contact you by e-mail: __Yes __No

Children living in the home:

Name: __________________________ Name: __________________________ Name: __________________________

Email address: ___________________________________

Age: _____ Age: _____ Age: _____

Relationship: ____________________ Relationship: ____________________ Relationship: ____________________

If client is a minor:

Mother’s Name: ______________________________ Home phone: _____________________ Work phone: _______________________ Cell phone: ___________________________

Father’s Name: ______________________________ Home phone: _____________________ Work phone: _______________________ Cell phone: ___________________________

Emergency Contact

Name: ____________________________________ Relationship: _________________________ Address: ______________________________________ Phone: ___________________________

Health Information

Please list any medical conditions you feel the therapist should be aware of: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Please list the medications the patient is currently taking, including the dosage: _______________________________________________________________________________________ _______________________________________________________________________________________

Complaints – If you have concerns or complaints regarding your treatment, please talk with me first. If there is no resolution there, you may contact:

Texas State Board of Examiners of Professional Counselors: Complaints Management and Investigative Section

P.O. Box 141369

Austin, Texas 78714-1369

Or call 1-800-942-5540 to request the appropriate form or obtain more information. _______________________________________________________________________________________