Letter Agreement For Provision Of Counselling Services Page 2
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5Former Clients:
I give permission to
BIOGRAPHICAL INFORMATION FORM
have
my
old
file
reactivated and viewed
Instructions
To assist us in helping you, please fill out this form as frankly as you can. Answer
by
my
current
only the questions you feel comfortable answering, keeping in mind that you will save much time
counsellor.
and effort by giving us full information. Like everything you say at PPC, the facts on this form will
be held in the strictest confidence.
Client’s
Initials:
Name(s) of ALL person(s) being seen: _____________________________
_________________________________________
LAST NAME
FIRST NAME(S)
PAYMENT DETAILS – Counselling will be paid for in the following manner:
___
EMPLOYER - Name of Company (IE: ABC Construction) _____________________________________________
Employee’s Name: _______________________
Department: _______________________
___
PERSONALLY – I am applying for REIMBURSEMENT from an Insurance Provider or another source.
(I understand that PPC does not directly invoice insurance providers and that I am responsible for obtaining reimbursement)
PERSONALLY - I have no opportunity for reimbursement
___
TREATY STATUS - Medical Services Branch will be covering counselling fees.
___
Treaty Number (10 digits) _________________________________
In ADDITION to the above,
___
____________________________
coverage is available through my spouse (or other parent) through
1. Your Full Address (including city and postal code): ___________________________________________________________
2. Home Phone: ____________________
Work Phone:______________________
Other Phone: _____________________
Messages OK?
Yes No
Messages OK?
Yes
No
Messages OK?
Yes No
3. Your Date of Birth: _______________________________________ Age:__________
Sex:
___Male ___Female
4. Your Title at Work: ________________________Years of Service: ____________ Seniority: ________________________
5. Spouse’s Name: ______________________Spouse’s Date of Birth:_____________ Spouse’s Occupation:________________
6. Names and Ages of Children: ____________________________________________________________________________
7. Does your family know you are seeking counselling? ___ Spouse ___ Father ___ Mother ___ Children
8. What is your PRIMARY reason for attending counselling at this time (IE: Marital, Addiction, Family, Stress):
_____________________________________________________________________________________________________
9. Who referred you to PPC?
___Self
___EFAP
___Psychologist/psychiatrist
___Social agency
___Relative
___Hospital/clinic
___Family doctor
___Friend
___ Unsure
___Phone Book
Has this person been here for counselling? ___Yes
___No
___ Other (______________________)
10. Present marital status:
___Never married
___Married now for the first time
___Married now for the second (or more) time
___Separated
___Divorced and not remarried
___Widowed and not remarried
___Living together
11. Years of formal education completed (include elementary, high school and post-secondary years):
1
2
3
4
5
6 7
8 9
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16 17
18 19
20+
Last updated 1/25/2007
C:ppcshareFormsBiographical Information Form.DOC
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Parent category: Letters