NEW CLIENT INFORMATION FORM
After reading the Disclosure and Treatment form, please complete the following questions.
Sign in to Google to save your progress. Learn more
Email *
Name of person completing this form: *
Today's Date *
MM
/
DD
/
YYYY
Ages of all clients *
Legal Names, Gender & Preferred Pronouns for all those seeking counseling *
Who referred you to Barbara Boutsikaris? *
What are you looking for: *
Your complete mailing address *
Cell phone numbers for each person attending counseling *
Email addresses for all clients *
Date of birth for all clients *
INSURANCE: At this time I am only a provider for BCBS and MVP. If you plan to use your insurance, please list your ID#, the name of the policyholder and birthdate, if different than yours. *

Please identify how you will pay for services, copays, deductibles, or missed appointments, etc. I accept Venmo, checks, cash (or credit cards with additional 3.75% fee).

 *

If paying by credit card, please list your credit card #, expiration date, CVV code and zip code. (If not using credit card, just type "not using.")

 *

Client's Highest Education Completed

 *

Name of your current employer, or if a student, the school you are attending:

 *

Relationship Status:

 *

What is your reason for seeking counseling now?

 *

Please check any issues you have experienced in the last 3-6 months.

 *
Required
Please list any major stressors that are impacting you currently. *
What do you do to cope or how have you coped until now? *

List your strengths, interests or experiences which contribute to your overall wellbeing.

 *

Who is your Primary Care doctor and what is their phone number?

 *

Do you give permission for Barbara Boutsikaris, MS LCMHC to contact your primary care physician listed above as needed? (Insurance requires me to ask this question.)

 *

Please describe any significant medical issues, allergies or hospitalizations:

 *

Please list all medications/dosages you are currently prescribed and who prescribed them.

 *

Do you (or someone else in your household) use alcohol and/or other drugs? If so, how much/often? 

 *
In the event of emergency, please list the person I may contact (other than yourself), their cell phone and relationship to you. *

Regarding firearms, please check all that apply:

 *
Required

In the event of an emergency, with whom would you be willing to leave your firearm(s) for a period of time until it was safe to have them again? (If not applicable because you do not have access to firearms in your home, please write "NA")

 *

I have read the Disclosure & Permission To Treat contract below and agree to abide by the contract.

 *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms