Client Information Form

Please note that fields with an * are required

Name*

Today's Date*

Address*

Primary Phone* (For minors, use Parent's/Guardian's Phone)

Cell Phone

Home Phone

Date of Birth*

Email* (For minors, use Parent's'/Guardian's Email)

Emergency Contact Name*

Emergency Contact Phone*

May I send correspondence or leave messages?*

Home address

Home phone

Cell phone

Referred by / How did you find Share Consulting?

I have read and understood the Disclosure & Agreement *Read Here (Opens in a separate window)

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Insurance Information (Optional)

Please complete if you are utilizing insurance. If possible, please attach a copy of both sides of your ID card.

Insurance Provider

Insured Name

Relationship to Insured

Insured Phone (if different)

Insured ID #

ID Card (.jpeg)

Select File

Insured Date of Birth

Group Number

Effective Date

Deductable & Co-Pay Amount

Insurance Phone (for Providers)

Send Claims to

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The following initial information gathering is completely confidential. You will not be judged by your answers, nor expected to maintain the status quo. Any question left blank will be reviewed in session. You are not required to answer all questions. Please be reminded that any private information that you will prefer not written down and that is not of a criminal or threatening nature, will be held in strict client confidence.

Describe briefly what brings you to counselling/therapy.

What are your goals for therapy? (Describe how you expect life to be different as a result).

Have you ever been in counselling/therapy before? How was it?

What are your hopes or expectations about therapy?

What are your fears, if any, about therapy?

Describe your most important relationships.

Who lives in your household (List # of people / ages / relationship to you)?

Please describe the strategies you most often use for coping with stress.

When was your last physical health checkup and what was the result?

Please list any accidents, surgeries, and hospitalizations with date/year.

Do you have any medical or physical conditions? If yes, what are they and how do they affect you?

Describe your sleep pattern (# of hours/day, regular/irregular,, restful/disturbed, light/heavy, wake up refreshed/tired)

How do you feel about how you eat? Describe your main meal of the day (menu/time/eat alone/with company)

What is your daily caffeine intake?

What kinds of exercise do you get, and how often?

Please list other health care practitioners with whom you are currently working, (Name/Title/Ph Contact).

Please list medications or supplements you are currently taking, (Name and Brand).

Please briefly describe your spiritual practices/beliefs, if any.

What other information would be of value in helping you?

Thank you for sharing this information. It will be held in confidence.

Before Submitting, review the form for missing or required information.

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Client Information Form

Insurance Information (Optional) Please complete if you are utilizing insurance. If possible, please attach a copy of both sides of your ID card.

Thank you for sharing this information. It will be held in confidence. Before Submitting, review the form for missing or required information. Scroll down to Submit

Insurance Information (Optional)

Please complete if you are utilizing insurance. If possible, please attach a copy of both sides of your ID card.

Thank you for sharing this information. It will be held in confidence.

Before Submitting, review the form for missing or required information.

Scroll down to Submit