Counseling Application

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

Name of Primary Caregiver(s)

Relationship to Client

Place of Education

How Long?

Grade

Performance

Siblings’ Names and Ages

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

Do you want to be added to the mailing list? NoYes

Email Address