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.
Client Name (First and Last Name)
Client's date of birth
Prefer not to say
Client's Address (House/Apt #, Street, City, State, Zip)
Home telephone number
Work telephone number
Cell/Mobile telephone number
If the client is a minor...
If client is a minor, parent(s) name(s)
If minor, who does the client primarily live with?
Mother and Father
If minor, what school does the client currently attend?
Grade/year in school?
If the client is an adult...
What is your occupation and where are you employed?
If you are in a relationship, what is your partner/spouse's name?
Highest level of education completed
Some high school
High school diploma
Some graduate school
In case of emergency...
In case of emergency, please contact (please provide a name and telephone number)
Reason for visit
What has caused you to seek out counseling?
What do you hope to achieve through counseling?
If you have received counseling in the past, please let me know who you saw (the provider) and when this occurred.
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