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 *
DOB *
MM
/
DD
/
YYYY
Age *
If Minor, Parent/Legal Guardian Name: *
Please fill N/A if you are an adult
Gender *
Marital Status
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Street Address *
City *
State *
Zip Code *
Primary Phone number *
May we leave a message *
May we identify as LUCE Mental Health Therapist? *
E-mail address *
May we send E-mail *
Emergency Contact *
Emergency Contact Telephone *
Your occupation/employment *
How did you hear about us
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