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NEW LIFE CHRISTIAN COUNSELING CENTER

 

CLIENT INTAKE FORM

 

 

CLIENT NAME ______________________________________________________________________________________________________

                                                 Last                                                        First                                                   Middle

 

ADDRESS ___________________________________________________________________________________________________________

                                                Street       (Include Apt # if applicable)                        City                                          State                     Zip

 

BEST PHONE NUMBER TO REACH YOU____________________________________________ and this is your CELL or your HOME

 

AN ALTERNATIVE PHONE NUMBER WOULD BE ___________________________________ and this is your _______________________

 

 

DATE OF BIRTH _______________________ (   ) MALE    (   ) FEMALE 

 

 

E-MAIL ADDRESS___________________________________________________________________________________________________

 

 

EMPLOYER _________________________________________________________________________________________________________

                                                      Name                                                                                                 Title

 

PHONE __________________________    OK TO CALL WORK? ___ YES ___NO                      OK TO LEAVE MESSAGE? ___YES___NO

 

 

SOCIAL SECURITY # ______________________________ MAIDEN NAME/A.K.A./OTHER NAME ________________________________

 

 

MARITAL STATUS? _____SINGLE   _____MARRIED (How many times?___)    _____WIDOWED    ____DIVORCED   ____SEPARATED

 

 

 

SPOUSE NAME ___________________________________________________________ DATE OF BIRTH____________________________

 

 

SPOUSE EMPLOYER _________________________________________________________________________________________________

                                                         Name                                                                                                              Title

 

PHONE ___________________________   OK TO CALL WORK?___YES ___NO                  OK TO LEAVE MESSAGE? ____YES ____NO

 

 

SOCIAL SECURITY # _______________________________ MAIDEN NAME/A.K.A./OTHER NAME _______________________________

 

 

REFERRED BY? ___________________________________ PHYSICIAN? ______________________________________________________

 

 

LAST MEDICAL EXAM _____________________________ MEDICAL CONDITION ____________________________________________

 

 

PRESENT MEDICATIONS _____________________________________________________________________________________________

 

 

NATURE OF PROBLEM FOR WHICH YOU ARE SEEKING HELP (BRIEFLY DESCRIBE) _______________________________________

 

____________________________________________________________________________________________________________________

 

 

IF WE ARE FILING INSURANCE FOR YOU AND YOU ARE NOT THE POLICY HOLDER PLEASE COMPLETE THE FOLLOWING:

 

POLICY HOLDER’S NAME__________________________________________   and his/her DATE OF BIRTH_______________________

 

POLICY HOLDER’S RELATIONSHIP TO YOU__________________________