New Client Screening Form printable pdf download

Choices Counseling & Resource Center, PA

SCREENING FORM

PLEASE PRINT CLEARLY

Name (first, middile initial, last) __________________________________

DOB (mo/day/yyyy) ______________________ SSN: ________ ‐ ____ ‐ ________

Address: ___________________________ City ____________ State ____ Zip __________

Telephone(s): Home: _____________________ Cell ___________________ Work ____________________

Email Address: ___________________________________

Guardian/Person Responsible for Account (circle one): self parent spouse

Parent/Spouse Name (if applicable): ________________________________

Signature of Person Responsible for Payment: ________________________________

EMERGENCY CONTACT INFORMATION (please list two people in case of emergency)

Name: __________________________________ Relationship: ___________________________

Home Phone: _______________ Work Phone: _______________ Cell Phone: _________________

Name: __________________________________ Relationship: ___________________________

Home Phone: _______________ Work Phone: _______________ Cell Phone: _________________

PRIMARY CARE PHYSICIAN AND/OR PSYCHIATRIST:

Physician: __________________________________________ Phone: ______________________________

Psychiatrist: ________________________________________ Phone: _____________________________

Signature here indicates permission for Choices Counseling & Resource Center, PA to

contact the above listed physician (s) for purposes of client care coordination:

______________________________________

EMPLOYMENT INFORMATION (for clients under 18, list parent place of

employment):

Client/Guardian:_______________________________________Spouse:_____________________________________

INSURANCE INFORMATION (we will file insurance but primary responsibility for

payment remains with client/guardian)

Name of Insurance Company: _____________________________________

Name of Insured: __________________________

Insured DOB: ____________________

Insured SSN: ________ ‐ ____ ‐ ________

Group ID: _______________________

Subscriber ID: ______________________

REFERRAL SOURCE

How did you hear about our clinic? Check all that apply:

Phone Book ___ Website ____ Primary Care Physician ____

Friend (please name) _____________________________________ Other _________________________________

Please provide name, if applicable: __________________________________

Revised 2/2010

New Client Screening Form