Client Information Form
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Email *
Client Name (First and Last Name)
Client's date of birth
MM
/
DD
/
YYYY
Gender
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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?
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
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.
After you click submit (below)...
Please read and complete the “Professional Disclosure Statement” form.  Any person seen for counseling must sign a copy of this document before we begin. This is required by the license that I hold in NC as a professional counselor.

If you will be receiving Telemental Health Services, you will also need to read and sign the “Telehealth Disclosure Statement”

Once you click submit, you will be provided a link in which you can access the Disclosure Statement.
Submit
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