Client Information Sheet - North Georgia Family Counseling Centers
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1North Georgia Family Counseling Centers, Inc.
(678) 242-9355
5100 S. Old Peachtree Rd.
Norcross, GA 30092
Client Information Sheet
Name
DOB
: _______________________________________________________________
: ______________________
Last
First
MI
Name you prefer to be called: ____________________________________________________
Address: _____________________________________________________________________
Street
City
State
Zip
Gender: ________________ Marital Status: ________________________________________
Phone: __________________
_______________________
________________________
Home
Work
Cell
Note: Please only provide numbers that can be used to contact you.
E-Mail: ___________________________________
BILLING SCHEDULING CLIENT COMMUNICATION
Please circle (above) how e-mail can be used
Work Status
:
FULL TIME
PART TIME
STUDENT
OTHER
IF STUDENT: NAME OF SCHOOL ____________________________________________________
Employer: _______________________________ Occupation: _________________________
Emergency Contact: _____________________________________ Phone: ________________
Last
First
Emergency Contact Relationship to You: ______________________________________
Responsible Party Information: (if other than self):
Name: ___________________________________ Relationship: ________________________
Address: _____________________________________________________________________
DOB: __________________ Gender: M or F Employer: _____________________________
How did you find out about our practice?
_____________________________________________________
For therapist use only
Location
Service: _______________ Per unit charge: ______
: _____________________________
Therapist: __________________Status: _______________ Diagnosis Code: ___________
Consent?
Symptom Checklist?
Release of Information?
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