Making life better
Making life better
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: _________________
**************************************************************************************************
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: __________________________________