CLIENT INFORMATION FORM

NAME: ___________________________ DATE OF BIRTH: __________________

Date of First Appt: _______________________ PHONE: Primary: ( c h w ) _____________________ Secondary: ( c h w ) _______________________ ok to leave V/T message? Y N

PARENT/GUARDIAN NAME (if child): ____________________________

Address: ______________________________________

City: ________________ ST: ______ Zip: ______________

Would you like e-mail/text reminders 24-hrs prior to your appts? How should we notify you: _________________

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COUNSELING NEEDS: Please check the issues that are currently affecting you:

0 Depression   0 Anxiety   0 Stress   0 Grief/Loss   0 Relationship Problems   0 Family Issues  0 Anger          0 Divorce   0 Childhood Issues  0 Substance Use    0 Mistrust     0 Panic  0 Money difficulties

0 Mood Swings   0 Dreams   0 Gambling    0 Marital Problems   0 Loneliness    0 Sadness    0 Eating difficulties  0 Problems w/ authority   0 Suicidal Thoughts    0 Isolation 

0 Other Concerns: ____________________________________________________________________

HOW DID YOU HEAR ABOUT ME? _______________________________________________

Can I thank them for the referral? Yes/No Referral Contact info: ________________________

MEDICAL CONDITIONS AND MEDICINES: __________________________________________

___________________________________________________________________________

PCM: __________________________________LOCATION: ___________________________ PHONE:________________________________ FAX: _____________________________

EMERGENCY CONTACT: _______________________    PHONE: ____________________

HEALTH INSURANCE:

Primary: ___________________________________ Secondary: __________________________________

Contact Info: __________________________________Contact Info: _________________________________

Pol. #: _____________________________________ Pol. #: ______________________________________

Primary Policy Holder 1: _____________________ Policy Holder 2: _________________________

PPH 1’s DOB: __________________________________PPH 2’s DOB: ___________________________________

PPH1’s Ph #: ___________________________________PPH 2’s Ph#: ___________________________________

Group/Plan Type: _______________________________ Group or Plan Type: ___________________________

Employer: _____________________________________Employer: ___________________________________

Deductible: _____________ Amt. Met: ____________ Deductible: _____________ Amt. Met: __________

Copay: ________________ Coins.: ______________ Copay: _________________ Coins: _____________

AUTHORIZATION Y N Auth 1: _______________________ Auth 2: _______________________________

NEEDED? # visits: ____ Dates: __________ # visits: _____ Dates:_________________

CLAIMS BILLING ADDRESS, and/or Payor ID: ______________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

Client Initials and Signature:

_____I am giving permission to contact my emergency contact person in the event of a medical emergency.

_____I have been provided with information, and/or have read, policies relating to the privacy of my health records, and am aware that I may have a copy of this policy to take with me at my request.

_____I have been informed and/or have read the financial policy of RoxAnne Koenig, MS, LIMHP, LLC and am aware that I may have a copy of this policy to take with me at my request.

_____I have been given and/or have read information regarding my treatment/sessions with RoxAnne Koenig, MS, LIMHP, and consent to my treatment. I am aware that I may have a copy of this policy to take with me at my request.

Client: _______________________________________ Date: __________________________________

Parent/Legal Guardian: _________________________ Date: __________________________________