Client Information

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Client Information

The Counseling Center at CELA: New Client/Client Update

Email *

Choose one option below *

I am a new client

I am updating my information

Name *

Date of birth *

Phone number *

Alternate phone number

Address *

Emergency Contact - Primary: (include their name, address, phone, email, and relationship to you) *

Emergency Contact - Secondary: (include their name, address, phone, email, and relationship to you) *

All payments are due at time of service. Are you able to pay the current rate for services? *

Yes

Will you be applying for a payment option? *

The Counseling Center at CELA offers the following payment options: (1) individualized payment plans; (2) sliding fee scales; (3) reduced rates; (4) limited availability pro bono (no charge) sessions. Please contact us for more information and to set up an individualized payment option.

Yes

May we leave messages on the phone number(s) listed above? *

Please give us complete information, if you agree to having The Counseling Center at CELA leave voicemail messages, regarding how you would like voicemail messages to be left. For example, do you want us to say the agency's name in voicemails we may leave? Do you want us to use your name or a different name in voicemail messages? Do you want us to leave voicemail messages only in certain situations, e.g., only appointment reminders?

May we email you at the email listed above? *

Are there only certain situations in which you would like us to email? For instance, only email appointment reminders and use the telephone to provide all other messages? NOTE: email correspondence is not considered to be a confidential medium of communication.

What is your preferred way of contacting and communicating with The Counseling Center at CELA outside of sessions? *

Please do not hesitate to ask any questions you may have, to ask for clarification of any information, or to ask for more information. Check the box below to let us know how you prefer contacting and communicating with The Counseling Center at CELA.

Telephone

Combination (email/phone)

Regular mail

Other:

Completing this form *

Write your name and the time and the date that you finished filling out this form in the spaces below. Providing your name as well as the date and the time you completed this form acknowledges that you: (1) have read and understood each individual question and the sections of this form, and the information requestion and/or provided; (2) have been given ample opportunity to ask any and all questions you may have; and (3) have provided information that is accurate and correct to the best of your knowledge.

YYYY

Time

Please sign/type your name in the space below to complete this form. Thank you! --- The Counseling Center at CELA. *

A copy of your responses will be emailed to the address you provided.

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