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	Client Intake Form General Information First Name: Last Name: Maiden Name: SS Number: (will get via phone.) Address: City: State: Zip Code: Gender: Choose One Female Male Date of Birth:   Responsible Party Information Name: Address: Contact Information   Home Phone: Ok to call Home?: Pick One Yes No Work Phone: Ok to call Work?: Pick One Yes No Other Information People In House: # Of Adults # Of Children: Counseling History: Therapist Name: Reason For Appointment: Medications (if any): Physician: Special Concerns: Attendent: Referred By: Extra Notes: Insurance Information Company Name: Phone Number: Policy Holder Name: SS Number:(will get via phone.) Group: Relationship To Client: Policy Type: Choose One Single Family/Group Copy of Insurance Card Requested: Pick One Yes No Employer Information   Employer Name: Address: Phone: City: State: Zip: You can choose to download the intake form and fill it out, speeding up your visit. Just download the file, open and print it, fill it out and bring it in to our offices. CLICK HERE to Download To read and print these form you will need adobe reader. Its free and you can download it at http://adobe.com.				Home About Us Melissa Sharp Mark Renner Anita Renner Services Individual Therapy Family Therapy Couples Therapy Gambling Addictions Family and Life Education Group Therapy Addictions Services Coaching FAQ’s Forms Client Intake Form Release of Information Insurance Information Notice of Privacy Fee Adjustment Consent to Treatment Patient Information Counseling FAQ's Contact Us   Upcoming Events Name: March Alcohol & Drug Education Class Date: March 25th 2012 Name: Enrollment is closed Feb Alcohol & Drug Education Class Date: Feb 4th, 2012 More Information