New Client Online Form

Name*
First Last
Date
Age*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer*
Work Location*
Home Phone
Work Phone
Cell Phone / Pager
Person responsible for payment*
Referred By:
Household Members
(Click the + to add more members)
Name Age Relationship? Are you the legal guardian?
Personal History
Highest level of education*
School attended*
Leisure Activities / Hobbies
Alcohol use*
Number of drinks per week
Cigarette use?*
Number of packs per day
What concern(s) brought you to counseling today?*
What changes do you want to see as a result of counseling?*

Prescription Medication	Dosage	Dr who prescribed	Reason for taking

Non-prescription medication	Dosage	How often	Reason for taking

Therapist / Facility Name	Dates Seen	Reason	Helpful?

Household Members

Name	Age	Relationship?	Are you the legal guardian?

Doctors involved in your healthcare	Specialty	Frequency seen

Home	Work

Home	Work	Cell