CLIENT FORM

PSYCHOTHERAPY - CLIENT INFORMATION FORM

Contact Information

Name *

Surname *

Age

Date of Birth (MM/DD/YY)

Phone *

Email *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

HOW DID YOU GET REFERRED TO ME? (Friend (who), Web search, Insurance, etc.)

Insurance Information

Insurance / EAP Program Name

Authorization #

# OF SESSIONS AUTHORIZED

In case of Emergency Contact Person

Name

Phone

Relationship to you?

Marital Status Please use dropdown

Name & Ages of Dependents/children

Name

Age

Name

Age

Name

Age

HOW WOULD YOU RATE YOUR CURRENT LEVEL OF DISTRESS? MILD = 1 MODERATE = 5 SEVERE = 10

List current medications
PAST OUTPATIENT MENTAL HEALTH TREATMENT?
YesNo
PAST INPATIENT ALCOHOL/DRUG REHABILITATION?
YesNo
FAMILY HISTORY OF MENTAL HEALTH PROBLEMS?
YesNo

Agreement

I understand that counseling is a confidential relationship and that my records cannot be disclosed without my written consent, as protected by law. I understand that Lynn Stravecky is required by state and Federal law to notify proper authorities without my written consent in the case of a threat of suicide, a threat of homicide, suspected child abuse, and spousal abuse. Further, I give my consent for Lynn Stravecky to contact the persons named herein, where I have indicated agreement. LESS THAN 24 HOUR CANCELLATION NOTICE WILL BE BILLED A $50.00 FEE. SIGNING DOCUMENT IS AGREEING TO MY OFFICE POLICY CHARGE.

Click Yes to agree. *

Yes, I agree.

Date

PSYCHOTHERAPY - CLIENT INFORMATION FORM

Contact Information

Insurance Information

In case of Emergency Contact Person

Name & Ages of Dependents/children

CURRENT REASONS FOR SEEKING PSYCHOLOGICAL SERVICES. (CHECK ALL THAT APPLY).

LIFE EVENTS OR CHANGES THAT HAVE OCCURRED IN THE PAST YEAR.

Agreement

Verification