Client Information
First Name
Last Name
Date of Birth
Age
Height
Weight
Eye Color
Insurance Company
Medicaid #
Please upload a picture of your (or the guardian's) I.D
Please upload a picture of your insurance card front and back.
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Home Phone Number
Cell Phone Number
Work Phone Number
Email
Employement Status
Full Time / Part Time
Retired
Unemployed / Not in Labor Force
In School
I Military / Veteran
Marital Status:
Single
Married
Gender
Male
Female
Student Status
Full Time Student
Part Time Student
Not a Student
School
Last Grade Completed
Race
White
Black or American African
Hispanic
Other
Preferred Language
Need Interpreter
Yes
No
Have you previously received or currently receiving mental health services?
Yes
No
Primary Physician Name
Phone Number
Last Seen:
Referred By:
Reason for Services
Parent / Guardian Information
Parent / Guardian Name
Relationship to Client
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Emergency Contact Information
First Name
Last Name
Relationship
Phone Number
Send
