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New Client Information
Please fill this out to contact me to request counseling services.
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Email
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Your email
Full Name (include preferred name if needed)
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Your answer
Email
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Your answer
Phone number
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Address
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Date of Birth
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MM
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DD
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YYYY
Insurance (including Carrier, Group #, Member ID #) or self pay?
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Your answer
Emergency Contact Name/Phone Number
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Your answer
Gender
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Female
Male
Nonbinary
Other:
Pronouns (she/her, he/him, they/them, etc.)
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Sexuality (heterosexual, lesbian, gay, bisexual, queer, asexual, etc.)
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Relationship Status
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Married/In a Relationship
Single/Divorced/Widowed
Other:
Household members (names/ages/relationship, including pets)
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Other Medical Providers (name/number/type of provider; PCP, psychiatrist, etc.)
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Known Diagnoses (psychiatric, medical, etc.)
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Medications (name/dosage)
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Treatment History (past hospitalizations, therapy, groups, etc.)
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Your answer
Substance Abuse History (substance, first use, last use, amount, etc.)
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Your answer
Reason for Seeking Counseling
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Your answer
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