Today's Date: ________________________________

Client Name:________________________________

Client Gender:          MALE          FEMALE

Client Date of Birth:_______________Age:________

Client Social Security #:________________________

Client Yrs. of Education:_______________________

If Client in school, name:_______________________

Relationship to Client:    SELF    PARENT/GUARDIAN

if  the Parent, name?___________________________

Home Address:______________________________

___________________________________________

___________________________________________

Home Phone: ________________________________

Cell Phone: _________________________________

INSURANCE: ______________________________

Insured's Name: _____________________________

Insurance ID Number:_________________________

Insurance Group Number:______________________

Insured's SS #:_______________________________

Insured’s Date of Birth:________________________

Certification # ?: _____________________________

Occupation: ________________________________

Employer: __________________________________

Employer Address: ___________________________

___________________________________________

Work Phone: ________________________________

Primary Care Provider (family doctor):_________________

PCP Practice: _______________________________

PCP Address: _______________________________

___________________________________________

PCP Phone:__________________________________

 
Client/Family  Job/School Problems:   YES      NO

List:________________________________________

List:________________________________________

Client/Family  Legal Problems:            YES      NO

List:________________________________________

List:________________________________________

Client/Family  Health Problems:           YES      NO

List:________________________________________

List:________________________________________

Client  currently taking any medication?   YES    NO

List:________________________________________

List:________________________________________

List:________________________________________

Client  Marital Status:     Sing    Mar    Div    Wid    Coh

Name if spouse or partner: _____________________

Client  Household Members   ( name / age / gender ):

 ___________________________________________

____________________________________________

____________________________________________

____________________________________________

________________________________________

Children Elsewhere (of adult client, or, siblings of minor) 

___________________________________________

___________________________________________

___________________________________________

Annual Family Income:__________________________

 

Is it ok for the PCP (family doctor listed) to be informed of your starting services here? It is a good idea!     

              YES      REFUSED     (mark one!)

  

Signed:_____________________________________