New Client Intake Form printable pdf download

New Client Intake Form

Rosemary T. Foos, LCSW-R

Counseling & Psychotherapy

1120 Crosspointe Lane Suite 4B

Webster, NY 14580

(585) 671-9680

New Client Intake Form

Date

Personal Data

Full (Legal) Name

Birthdate

Street address

City, State, Zip

Phone: (home)

(work)

(cell phone)

Please check the preferred method for communication.

May I contact you, and leave a message at any of the above numbers or email address?

Yes [ ] No [

]

If not, please indicate limits of communication below.

Employment Status

Employer_ __________________Occupation

If you’re a student, list school and level/grade

Marital Status:

[ ]Single [ ]Married [ ]Domestic Partner [ ]Separated [ ]Divorced [ ]Widowed

Name of spouse or partner:

Emergency Contact: ______________________________Relationship to client

Emergency Contact’s Phone number

Medical Contacts

Primary Care Physician’s First Name

Last Name

__, MD

If you see a physician assistant in your PCP practice, you may list their name in addition to MD.

Primary Care Physician Address

Primary Care Physician’s Phone #

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New Client Intake Form