"Turning Points" Counselling Centre

Mental Health Counselling & Consulting

Intake: Client Info Form

In order to serve you better, it would be helpful to have the following information.

Please be as complete as possible. All information is strictly confidential and protected from disclosure as indicated by the laws of this state.

 

CLIENT INFORMATION

Name:

Address:

City:                                                 State:                                    Postal Code:

Mobile Phone:

Email:

Employer/School/University:

Occupation:

Emergency Contact:

Medicare #:                                                                                   Ind. Ref #:

Medicare Exp Date:

MAIN PROBLEM / CONCERN / ISSUE YOU SEEK TO ADDRESS

 

 

 

HOW DID YOU LEARN ABOUT “TURNING POINTS”?

  Phone Book       Newspaper □   Internet

  Client Reference □   Personal Reference       Insurance Health Fund

  Other Professional (if so, whom?): 

  Physician (if so, whom?): 

  Other (please specify): 

 

GP / MEDICAL INFORMATION

GP:

Practice Name:

Address:

City:                                                 State:                                    Postal Code:

Provider Number:

Phone:

Email:

 

PHYSICAL / HEALTH ISSUES

 

 

 

MEDICATIONS

%d bloggers like this: