New Clients

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Gender

Marital Status

Phone

(###)

###

####

Email Address

FINANCIALLY RESPONSIBLE PARTY

(IF OTHER THAN CLIENT)na

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relationship to Client

Phone

(###)

###

####

PRIMARY INSURANCE INFORMATION

Primary Insurance Co.

Primary Insurer Phone

(###)

###

####

Mental Health Carrier

Mental Health Carrier Number

(###)

###

####

Policy Holder's Name

First Name

Last Name

Policy Holder's D.O.B

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy ID #

Group ID #

Social Security #

Relationship to Client

Employer

Effective Date

YYYY

SECONDARY INSURANCE INFORMATION

Secondary Insurance Co.

Secondary Insurer Phone

(###)

###

####

Mental Health Carrier

Mental Health Carrier Phone

(###)

###

####

Policy Holder's Name

First Name

Last Name

Policy Holder's D.O.B

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Policy ID #

Group #

Social Security #

Relationship to Client

Employer

Effective Date

YYYY

BACKGROUND INFORMATION

Names and ages of members of household

What is the reason, in brief, you are seeking counseling

How long has the situation existed

Has counseling been previously sought?

Name of provider (if yes)

Previous provider phone

(###)

###

####

I give permission for Bruce Turnquist & Associates to contact previous provider

Yes

Family physician

First Name

Last Name

Physician's phone

(###)

###

####

Is the Client presently taking any medications?

Please include dosage and prescribing physician

Medical conditions or allergies

How did you hear about us?

May we contact them to thank them for the referral?

Yes

Religious community affiliation