Client Information Form
Client Information Form
Please complete this Client Information Form Template to gather and record essential details about your clients, including contact information, preferences, and business needs.
Date
A. Identification
Full Name
Date of Birth
Phone number
Address
May we send you a message?
May we leave a message?
B. Referral Information
Name
C. Medical Care
Clinic/Doctor's Name
Phone number
Address
D. Current Employer Information
Employer Name
Address
Job Title and Duties
E. Education and Training
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Form |
To |
School |
Major |
Adjustment |
Graduate |
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1 |
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2 |
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Thank you for submission!
We appreciate you taking the time to submit.
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F. Health and Mental Health Information
Have you previously received any type of mental health services?
Are you currently taking any prescription medication, including anti-depressants?
How would you rate your current physical health?
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Poor
-
Unsatisfactory
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Satisfactory
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Good
-
Very Good
How would you rate your current sleeping habits?
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Poor
-
Unsatisfactory
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Satisfactory
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Good
-
Very Good
How often do you engage in recreational drug use?
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Daily
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Weekly
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Monthly
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Infrequently
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Never
G. Emergency Information
Name
Phone number
Significant/nearest friend or relative not living with you
H. Financial Information
Insurance Company
Phone number
Policy #
Group #
Name of Insured
Relationship of Insured
Insured's Date of Birth
This is strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
