Minor Client Information Form - Centerpoint Counseling

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CenterPoint Counseling - MINOR Client Information
Date of Initial Session:_____________
Therapist:__________________________
Male
Client/Child’s Name____________________________
Female
Date of Birth:_______________
Address_________________________________ City_______________State_______Zip __________
Home Phone(____)__________________Current Grade _________ School______________________
Emergency Contact __________________________________________________________________
Name
Relationship
Phone
Parent/Guardian 1 Name____________________ Date of Birth:_________ Relationship to client: ___________
Address ____________________________ City____________State____Zip _______ Employer _____________
Cell Phone (____)_______________ Work Phone (____)_______________ Email: ________________________
Parent/Guardian 2 Name____________________ Date of Birth:_________ Relationship to client: ___________
Address ____________________________ City____________State____Zip _______ Employer _____________
Cell Phone (____)_______________ Work Phone (____)_______________ Email: ________________________
Billable Party Name
__________________________________________
(If different than Client Name listed above):
Address
___________________________ City_______________State_______Zip__________
(If Different)
Cell Phone (____)_______________ Work Phone (____)_______________ Email: ________________________
Used for statistical analysis only. Information is compiled and anonymity of all clients is maintained.
Annual Household Income
How did you hear about us?
Are you a member of, or do you regularly attend
(please identify)
Under $30,000
Attorney________________________
Yes
No
Second Presbyterian Church?
$30,000 - $40,000
Friend _________________________
Are you a member of, or do you regularly attend
$40,000 - $50,000
Family _________________________
New Hope Presbyterian Church? Yes
No
$50,000 - $60,000
Pastor _________________________
$60,000 - $70,000
Physician_______________________
If not at Second or New Hope, do you regularly
$70,000 - $80,000
Insurance_______________________
Yes
No
attend another church?
If Yes, which church?_____________________
$80,000 - $100,000
Internet(website) _________________
Over $100,000
Other__________________________
Communication of Private Mental Health Information: There may be times when CenterPoint staff needs to leave you a
voicemail in regards to appointment times, account questions, or other reasons relating to your care. Please inform us if you
have a preferred number for messages. When responding to client initiated contact, we will respond using the requested
method you specify.
Minor/Child Consent: I have legal authority to do all things necessary with regards to seeking
therapy/counseling for my child(ren). I give my permission of treatment for my child(ren) to receive
therapy/counseling from CenterPoint Counseling. I also acknowledge that the above information is
correct.
___________________________________________________________________________________________________
Parent/Guardian Signature
Printed Name
Date
___________________________________________________________________________________________________
Parent/Guardian Signature
Printed Name
Date
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