New Client Questionnaire (Adult)

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

Client Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Medical History

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your visit

Date of your last physical exam

Is there a chance that you are pregnant?

Yes No

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies to medications?

Emergency Contact Information

Add another emergency contact

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Dr. Raymond Rogers

Registered Psychologist

Raymond Rogers has been practicing for more than 20 years, specializing in family and couples therapy. He has a warm, approachable style that provides a safe, comfortable environment conducive to introspective conversation and mutual listening. Dr. Rogers welcomes clients of all ages and backgrounds.

+1-613-555-0122
RaymondRogers
RaymondRogers
RaymondRogers
129 Loretta Ave N, Ottawa, ON, K1Y 2J7, CA