Office Use Only

Therapist_________________

Ins. Info Attached?_________

OK to Call? ______________

PATHWAYS CHRISTIAN COUNSELING

232 W. Hardin St, Findlay, Ohio 45840

419-423-7812 419-423-9877 (fax)

Client Confidential Information

Client’s name_________________________________ Birth date ________________________

Client’s address __________________________________________ City __________________ Zip__________ Phone Number:___________________(home) ______________________ (work) Can we leave a message? _______Social Security #__________________________________

Spouse’s name _______________________________ Birth date __________________________

Parent’s names (for minor clients) ___________________________________________________

Address (if different from client) ____________________________________________________

In case of emergency, please contact:

Name ____________________ Phone: _________________ Relationship to client ____________

Or:

Name ____________________Phone __________________ Relationship to client ____________

Client’s employer ________________________ Occupation____________________________

Spouse’s occupation ______________________ SS # _________________________________

Others living in the home:

Name Age Name Age

___________________ __________ _______________________ _____________ ___________________ __________ _______________________ _____________

If there is a history of alcoholism, substance abuse, mental illness or prolonged physical illness, please describe:_______________________________________________________________________

Please describe any of the above which are current _____________________________________

______________________________________________________________________________

Current medications (and dosage) taken by client___________________________________________

_______________________________________________________________________________

Significant medical problems___________________________________________________________

If you have had previous psychiatric care or counseling, please indicate where, for what purpose and for how long ________________________________________________________________________

Please describe why you are seeking counseling at this time__________________________________

__________________________________________________________________________________

Who referred you to us? ___________________________ May we thank him/her for the referral?____

Is your visit employment or accident related? Please Explain ______________________________________ _

Insurance Information:

Please complete or ask receptionist to make a copy of your insurance card.

Primary insured name ________________ Insurance Company______________________________

Policy Number ______________________ Group Number __________________________________

Phone Number______________________ Claims Address_____________________________