Family & Addiction Counseling llc Client Information Form
Please complete our online intake form so we can prepare for your care. If you have any questions contact glen@familyaddictioncounseling.com or call/txt (808) 494-6066. We look foward to meeting you!
Name
Your answer
Birthday
MM
/
DD
/
YYYY
Gender
Marital Status
Address
Your answer
Cell Phone
Your answer
Other 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
Your answer
Insured Date of Birth
Your answer
Insured Relationship to Client
Insurance Plan
Insurance Policy Number
Your answer
Insurance Group
Your answer
Social Security Number (for Tricare only)
Your answer
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