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Client's full name ________________________________________________________________________________________________ Address ___________________________________________________ Phone number (home and cell, if applicable) ___________________________________________________ Social Security number ______________________ Age ______________________ Date of birth ______________________ Gender ______________________ Marital status ___________________________________________________ Referral from? ________________________________________________________________________________________________ Please briefly describe your previous treatment ________________________________________________________________________________________________ Your current medications, if any ________________________________________________________________________________________________ Please list your current household members ________________________________________________________________________________________________ Please briefly describe your reason for your psychotherapeutic interview ___________________________________________________ Employer ___________________________________________________ Work phone ________________________________________________________________________________________________ Employer's address ___________________________________________________ Spouse/guardian name ___________________________________________________ Spouse/guardian date of birth ___________________________________________________ Spouse/guardian Social Security No. ___________________________________________________ Spouse/Guardian employer ___________________________________________________ Primary care doctor ___________________________________________________ Phone number of primary care doctor ___________________________________________________ Primary insurance company ___________________________________________________ Phone number of your primary insurance company ________________________________________________________________________________________________ Address to mail claims ___________________________________________________ Insured ______________________ Insured ID number ______________________ Insured Group number |