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


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


Type your full name

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