re: New Client Questionnaire (Confidential)

re: therapy

Please correct the errors described below.

Client Information

Include parent/legal guardian name(s) and phone numbers.
If you were referred to me please include their name so I may thank them

Emergency Contact Information

History

General Health Information

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Additional Information

Signature

Type your full name

Your message will be encrypted and can only be read by Donna Kennedy, LCSW, LCADC.