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CLIENT INFORMATION
Client’s Name *
Relationship to Caller
Address
Best Number to reach you? *
Times of availability for counseling appointments
Date of Birth
Sex MF
Nature of the Problem
Duration of the Problem
Assaultive NoYes
Alcohol/Drugs NoYes
Suicidal NoYes
If yes explain
Previous Counseling NoYes
If Yes with who
when
If yes, why was previous counseling terminated?
Marital Status SMDWSep
How Long Married/Divorced/Widowed/Separated
Spouse’s Name
Spouse Date of Birth
Childrens’ Names and Ages
IF CLIENT IS MINOR
Name of Primary Caregiver(s)
Relationship to Client
Place of Education
How Long?
Grade
Performance
Siblings’ Names and Ages
ADMINISTRATIVE
How were you planning on paying for the counseling Out of PocketInsuranceBoth Out of Pocket & Insurance
Fees Quoted: Intake
OV
Sliding Scale NoYes
Estimated Annual Income
Mental Health Insurance Provider
Insurance Phone Number
Insured’s Name
Insured’s Policy Number
Insured’s Employer
Client Relationship to Insured
Effective Date
MAILING LIST
Do you want to be added to the mailing list? NoYes
Email Address
Christwise Counsel
WPCMI