New Client Questionnaire

If this is an emergency, call:

Client Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Mailing Address

Insurance Type

Insurance #

Group ID# (if applicable)

Private Insurance Holder's Name and Date of Birth

Social Security Number

Applicable copay amount

Name of Parent or Guardian

Does the Parent/Guardian have legal custody of the minor?

Yes No

Name of Referral Source

Reason for seeking services (client need or problem)

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

Preferred time of day for an appointment

Previous outpatient treatment?

yes no

Any previous psychiatric hospitalizations?

yes no

Your information will be encrypted.