Client Contact Form
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1CLIENT CONTACT FORM
This completed form helps my office contact you in the most efficient and confidential manner. As a
courtesy, we make it a practice to remind you of your appointment. You will receive an email reminder a
few days before your appointment. Please confirm your appointment by responding to the email. Please be
advised, there are times when my staff may be out of the office due to illness, vacation or holidays and will
be unavailable to send out emails. The responsibility to remember your appointment is ultimately yours. If
you miss an appointment without providing at least a 24-hour notice, you will be responsible for paying for
the session in full (emergencies reviewed on a case-by-case basis). If you notify the office at least 24-hours
in advance, your session time can be offered to someone from my waiting list.
P
LEASE PRINT AND PROVIDE ALL INFORMATION REQUESTED
Client Name: ______________________________________
Date of Birth: ___________________
Home Phone: (__ __ __) __ __ __ - __ __ __ __
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May we contact you at the above number?
Yes
No
Emergency only
In the event you are not available, may we leave a message with anyone answering or leave a
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voicemail message?
Yes
No
Emergency only
Special note or instructions: ___________________________________________________________
__________________________________________________________________________________
Cell Phone: (__ __ __) __ __ __ - __ __ __ __
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May we contact you at the above number?
Yes
No
Emergency only
In the event you are not available, may we leave a message with anyone answering or leave a
□
□
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voicemail message?
Yes
No
Emergency only
Special note or instructions: ___________________________________________________________
__________________________________________________________________________________
Work Phone: (__ __ __) __ __ __ - __ __ __ __
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May we contact you at the above number?
Yes
No
Emergency only
In the event you are not available, may we leave a message with anyone answering or leave a
□
□
□
voicemail message?
Yes
No
Emergency only
Special note or instructions: ___________________________________________________________
__________________________________________________________________________________
E-mail Address: ____________________________________________________________
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May we contact you at the above e-mail address?
Yes
No
Emergency only
Special note or instructions: ___________________________________________________________
__________________________________________________________________________________
NOTE: I am unable to guarantee the confidentiality of e-mail correspondence.
Please call the
office with any sensitive and/or private health information at 512-249-5001.
Please do not use
email to communicate regarding an emergency situation, as I cannot guarantee a prompt reply.
Contact the office in the event of an emergency. Email is used for scheduling and general
information not as a regular form of client communication.
Client Signature: __________________________________________ Date: _____________________
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LEASE NOTIFY MY OFFICE OF ANY FUTURE CHANGES TO THIS INFORMATION AS SOON AS POSSIBLE
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Parent category: Business