New Client Online Form Step 1 of 2 50% Name* First Last Date MM slash DD slash YYYY Age* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer* Work Location* Home PhoneWork PhoneCell Phone / PagerPerson responsible for payment* Referred By: Household Members(Click the + to add more members)NameAgeRelationship?Are you the legal guardian? Personal HistoryHighest level of education* School attended* Leisure Activities / HobbiesAlcohol use*NeverOcassionalWeeklyNumber of drinks per week Cigarette use?*YesNoNumber of packs per day What concern(s) brought you to counseling today?*What changes do you want to see as a result of counseling?* Medical History(click the + to add additional spaces)Doctors involved in your healthcareSpecialtyFrequency seen Current health problemsMedicationsPrescription medications* Yes No (click the + to add additional medications)Prescription MedicationDosageDr who prescribedReason for taking Non-prescription medication* Yes No (click the + to add more medications)Non-prescription medicationDosageHow oftenReason for taking Past HospitalizationsPast Hospitalizations or Treatment?* Yes No (Medical, Psychiatric Care, Chemical Dependancy)DatesReasonHospital / Facility Previous Counseling, EAP, or Chemical Dependency ServicesPrevious Counseling or Services?* Yes No ListTherapist / Facility NameDates SeenReasonHelpful? How May We Contact You? (please list all that are okay)By mail?HomeWork By phone?HomeWorkCell I, the undersigned, hereby voluntarily request to receive clinical services from Vidisha A. Patel, Ed.D. I understand that these services may include individual, group, family and/or marital therapy. I acknowledge that no guarantees have been made to me as to the effect of therapeutic assessments, therapy, treatment or care of my condition. I further understand that before beginning any treatment procedure I will be given an explanation of the nature and purpose of such treatment and any probable risks involved. I may refuse any and all treatment at any time. I understand that the information I share with the therapist will be held in the strictest confidence with the exception of the following reasons as outlined by Florida Statutes: (1) you consent in writing (2) someone’s life or safety is seriously threatened (3) disclosure is required by law (4) you file a benefit claim and the claims payor requires information I understand that I am responsible for the payment of all services and I agree to provide payment should my insurance carrier fail to do so. I have read the Consent For Treatment and agree to its terms.* Yes No Δ
