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Personal Information - HIPPA - Disclosure Statement

First name

Last name

Mobile Phone

Home Phone

Work Phone

Birthday required

Occupation

What school do you attend?

Select an Address

IF A MINOR:

Parent/Guardian Name(s)

Parent/Guardian Email(s)

Parent/Guardian's Mobile Phone

Parent/Guardian's Work Phone

Sibling's Name(s)/Age(s)

IF A MARRIED:

Spouse's Name

Spouse's Mobile Phone

Spouse's Email

Occupation

Children's Name(s)/Age(s)

ADDITIONAL INFORMATION:

How did you hear about this practice?

Have you had any previous counseling/psychiatric care? With whom?

Please list all medications

Primary Care Physician

Phone

The above information is true to the best of my knowledge:

Signature of Client/Guardian

Date required

Signature of Minor if 15 or Older

Date

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