Associated Counseling Group

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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:		Date of Birth:

Responsible Party Information

Name:

Address:

Contact Information

Home Phone:		Ok to call Home?:
Work Phone:		Ok to call Work?:

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:
Copy of Insurance Card Requested:

Employer Information

Employer Name:
Address:
Phone:
City:
State:
Zip:

You can also 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.