Village
Counseling Services
CLIENT INFORMATION
Date _________________________
Name: __________________________________________________________________
Phone: (Hm) ________________ (Wk) _________________ (Cell) ________________
Address:________________________________________________________________
City:
Is it ok for us to send billing statements, newsletters, or any other mailings to the above address?
yes no, please use the following address: _________________________________
________________________________________________________________________
Social Security #:__________________ Email: _________________________________
Sex: Male __________ Female __________ Date of Birth: ______________________
Others living at home: _____________________________________________________
Employer: ________________________________ Occupation: ____________________
How long have you worked there? _________ How long in this occupation? __________
Education: (List highest level of education attained) _____________________________
Primary Physician: ________________________________ Phone: _________________
List any significant health problems: __________________________________________
________________________________________________________________________
________________________________________________________________________
List any medications you are taking and the dosage: _____________________________
________________________________________________________________________
Have you seen a counselor or psychotherapist before? YES ____ NO ____
If yes, when and with whom? _______________________________________________
Give a brief description of treatment : _________________________________________
________________________________________________________________________
How were you referred to my office? _________________________________________
Who may I thank for referring you? _________________________________________
Name and phone number of nearest relative ____________________________________