MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C96101.D68D0F00" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C96101.D68D0F00 Content-Location: file:///C:/CF65A114/ClientInformationSheet.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Village Counseling Services

Village Counseling Services

= 5311 Kirby Dr. Suite 204  ·  Houston, Texas 77005=   ·  713-533-9811

 

 

CLIENT INFORMATION

 

   &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          Date _________________________=

 

Name: ________________________________________________________________________

Phone:  (Hm) ________________  (Wk) _________________ (Cell) ____= __________________

Address:_____________= __________________________________________________________

City:____________________________  State<= /st1:PlaceType>: _________________  Zip:_______= ____________

 

Is it ok for us to se= nd billing statements, newsletters, or any other mailings to the above address= ?

 

 yes   no, please use the following address: ________________________________________

_____________________= _________________________________________________________=

 

Is it ok for us to co= nfirm appointments?  yes   no

If yes, how should we= contact you?         =     email        cell   &nbs= p;    home       == 450; work

 

Social Security #:__________________ Email: _______________________________________<= span style=3D'font-size:10.0pt'>

 

Sex: Male __________<= span style=3D'mso-spacerun:yes'>  Female ___________  Date of Birth:  ____________________________

Others living at home= : ____________________________________________________________

 

Employer: ___________= ______________________ Occupation: _________________________

How long have you wor= ked there? _________ How long in this occupation? ________________

Education:  (List highest level of education attained) ___________________________________

 

Primary Physician: ________________________________ Phone: ________________________

Psychiatrist:________= ______________________________ Phone:________________________=

List any significant = health problems: ________________________________________________

_____________________= _________________________________________________________

_____________________= _________________________________________________________

List any medications = you are taking and the dosage: ____________________________________

_____________________= _________________________________________________________

 

Have you seen a couns= elor or psychotherapist before?      yes     no

If yes, when and with= whom? ______________________________________________________

Give a brief descript= ion of treatment : _______________________________________________

_____________________= _________________________________________________________

 

How were you referred= to my office? ________________________________________________

Who may I thank for r= eferring you? _________________________________________________

 

Name and phone # of n= earest relative ________________________________________________=

Relation? ___________= _______

 

*= If you receive emails from our office, your private information may be viewed = by anyone with access to your email. We cannot guarantee the privacy of your personal information through email.

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Villa= ge Counseling Services

 

= 5311 Kirby Dr. Suite 204  ·  Houston, Texas 77005=   ·  713-533-9811

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