Behavioral Health Assessment
Client History and Information
Thank you for choosing LUCE Mental Health Therapist. Please answer the questions
below as honestly and completely as possible so that we might know how to best support you on
your journey toward health and wellness.
Client's Name *
Your answer
DOB *
MM
/
DD
/
YYYY
Age *
Your answer
If Minor, Parent/Legal Guardian Name: *
Please fill N/A if you are an adult
Your answer
Gender *
Marital Status
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Primary Phone number *
Your answer
May we leave a message *
May we identify as LUCE Mental Health Therapist? *
E-mail address *
Your answer
May we send E-mail *
Emergency Contact *
Your answer
Emergency Contact Telephone *
Your answer
Your occupation/employment *
Your answer
How did you hear about us
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