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CIA Gateway Workbook

This document contains a new client information form requesting personal details, contact information, health insurance details, and emergency contact information to set up a new client for mental health counseling and consultation services.

Uploaded by

Sarah Couch
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
270 views

CIA Gateway Workbook

This document contains a new client information form requesting personal details, contact information, health insurance details, and emergency contact information to set up a new client for mental health counseling and consultation services.

Uploaded by

Sarah Couch
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CA

Couch + AndersonLLC
-----------
Mental Health Counseling and Consultation

NEW CLIENT IN FORMATION

Full Legal Name

□-□-□
Preferred Name Date of Birth Age Social Security Number

Contact Information

Address

□
□ -1�
E-Mail Phone Alternative Phone

D
□□□ □□□
Call Text Leave Voicemail Call Text Leave Voicemail
Please indicate all ways
that we may contact you.

Personal Information

Sex Gender Preferred Pronouns

Sexual Orientation Relationship Status Race+ Ethnicity

Preferred Language Religious/Spiritual Beliefs Employment Status

Occupation Employer School / Grade

Military Service: Branch Military Service: Dates Served


Please complete if client is a minor

□ -1�
Legal Guardian Name #7 Occupation+ Employer Phone

D
□ -1�
Legal Guardian Name #2 Occupation+ Employer Phone

D
Person Responsible for Payment

Address

□
Emergency Contact

Name

Relationship

Phone Number E-Mail

2
Health Insurance Information

Insurance Type Insurance Payer Member ID

Plan ID Group ID Copay

Coinsurance Deductible Insurance Payer Phone+ Fax

□-□-□
Primary Person Insured Relationship to Client Primary Insured Social Security Number

Primary Insured Date of Birth Primary Insured Employer

Primary Insured Address

□
Secondary Insurance Type Insurance Payer Member ID

Plan ID Group ID Copay

Coinsuranee Deductible Insurance Payer Phone+ Fax

□-□-□
Primary Person Insured Relationship to Client Primary Insured Social Security Number

Primary Insured Date of Birth Primary Insured Employer

Primary Insured Address

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