Great Lakes Counseling Services, LLC
12930 James St Suite 110, Holland MI 49424
2675 44th St., SW, Grandville, MI 49519
Demographic Information
First Name
Middle Initial
Last Name
Social Security #
Street Address
City
State
Zip Code
Telephone Number
Date of Birth
MM
/
DD
/
YYYY
Age
Gender
Emergency Contact:
Persons to be contacted in case of an emergency. Please list two contacts.
Contact #1
First & Last Name
Relationship
Home Phone
(Cell)
Business Phone
Address
Contact #2
First & Last Name
Relationship
Home Phone
(Cell)
Business Phone
Address
Primary Care Physician
Name of Physician
Address
Office Phone Number
Office Fax Number
Insurance Card Information
Insurance Co. Name
Member Benefits Phone Number
Address
(To Send Claims)
I.D. #
Group #
Plan #
Insured's Name
(Policyholder/Responsible Party)
Insured's SSN #
Insured's Birth Date
MM
/
DD
/
YYYY
Relationship to Insured
Personal History
Have you had?
Yes
No
Recurrent Headache
Eye Problem
Ear Problem
Nose Problem
Throat Problem
Thyroid Disorder
Heart Murmur/Heart Disease
Heart Palpitations
High/Low Blood Pressure
Anemia/Sickle Cell
Bleeding Disorders: Hemophilia/Other
Hepatitis
Kidney/Bladder Disorders
Pneumonia/Bronchitis
Tuberculosis
Seasonal Allergies/Hay Fever
Asthma
Epilepsy/Seizures
Dizziness/Fainting with Exercise
Head Injury/Concussion
Bone/Joint Injuries
Stomach/Intestinal Problems
Diabetes
Eating Disorder
ADD/ADHD
Chicken Pox/Immunization
Mononucleosis
Alcohol Abuse
Drug Abuse
Sexual Assault/Violence
Testosterone/Menstruation Issues
For Women: Age of first period?
Pain - Specify below:
Surgeries:
Hospitalizations:
Allergies:
Medication Allergies:
Medication Currently Taking:
Any other disease, illness, past surgeries, permanent disabilities, or explanations of any marked concerns from the list above?
How did you hear about us?
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