Client History

Being as detailed as possible helps your intake process.

Please correct the errors described below.

Client History

You may get appt reminder texts at this number
Apartment, Suite, Building Number
PHP, BCBSM, Cofinity, McLaren etc.
Will be on your card
Name of Person on Insurance Card
Guardian, Parent, Spouse, Self
Depression, anxiety, bipolar, panic attacks
examples may be Lexapro, seroquel, venlafaxine, xanax

Medical History

Please include supplements and vitamins as well

Substance Use History

Social History

Best friends, business partners, childhood friends, etc.

Strengths/Limitations

Your information will be encrypted.

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