Initial Contact – Balanced Life Counseling

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Initial Contact Form

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Today's Date*
Date Format: MM slash DD slash YYYY
Client Information
Client's First Name*
Client's Middle Initial*
Client's Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address City State ZIP Code
Phone Number*
Call/Text Appt. Reminder?*
- Yes
- No
Emergency Contact's Name*
Emergency Contact's Phone Number*
Responsible Party
First Name of Insured*
Middle Initial of Insured*
Last Name of Insured*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone Number*
Call/Text Appt. Reminder?*
- Yes
- No
Relationship to Client*
Other Information
Method of Payment*
- Private Pay
- Insurance
Name of Primary Care Physician*
Physician's Address*
City State
Medical condition(s) and medication(s)
Has Client had prior counseling/therapy?*
- Yes
- No
Date of prior counseling/therapy*
Date Format: MM slash DD slash YYYY
Reason(s) for Seeking Evaluation*
How long has this been a problem?*
Please rate the severity of client's condition on a scale of 1 to 10 (1 being mild and 10 being severe)*
Client (parent/guardian) Signature*
Name
This field is for validation purposes and should be left unchanged.

Please be aware that although confidentiality between myself and my clients is protected by law, the confidentiality of email or any other interaction through this web site cannot be guaranteed.

Initial Contact Form

Client Information

Responsible Party

Other Information