Client Information Form
This is a secure client information form. Chadwick Royal, PhD, LPCS has signed a (HIPAA) Business Associate Agreement (BAA) with Google which covers the security of the content contained in this form.
Email address *
Client Name (First and Last Name)
Your answer
Client's date of birth
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DD
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YYYY
Gender
Client's Address (House/Apt #, Street, City, State, Zip)
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Home telephone number
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Work telephone number
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Cell/Mobile telephone number
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If the client is a minor...
If client is a minor, parent(s) name(s)
Your answer
If minor, who does the client primarily live with?
If minor, what school does the client currently attend?
Your answer
Grade/year in school?
Your answer
If the client is an adult...
What is your occupation and where are you employed?
Your answer
If you are in a relationship, what is your partner/spouse's name?
Your answer
Highest level of education completed
In case of emergency...
In case of emergency, please contact (please provide a name and telephone number)
Your answer
Reason for visit
What has caused you to seek out counseling?
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What do you hope to achieve through counseling?
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If you have received counseling in the past, please let me know who you saw (the provider) and when this occurred.
Your answer
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