Gayle G. Anderson, M.A.

, PLPC
Supervisor: V. David Weiss, M.S., LPC
Client Information

Basic Information:

Client Name:

Address:

Home Phone: Work Phone: Cell Phone:

Email:

Birth date: Social Security Number:

Employer:

Position:

May I leave a message on your voice mail or answering machine? Yes No

Insurance Information:
Do you have Behavioral Health Insurance? Yes No

Primary Coverage: __________________ Type of Coverage: ____________

Group Number: _______________ Participant Number: _________________

Secondary Coverage: __________________ Type of Coverage: ____________

Group Number: _______________ Participant Number: _________________

Guardian/Person(s) to contact in Case of Emergency:

Name: Phone:

Name: Phone:

Type of Services Sought: Individual Group Therapy Couples Family

Expectations of Service:

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 Gayle G. Anderson, M.A., PLPC
Supervisor: V. David Weiss, M.S., LPC
Client Information

Are significant others willing to be involved in supportive services as well?

Yes No Maybe Later On

Names: Relationship:

History:

Has Client been involved in therapy/counseling previously? Yes No

If yes, name(s) of service provider(s):

Length of time in treatment: Less than 6 months 6 – 12 months > 1 year

Reason for termination

Will client sign release? Yes No If no, explain:

Hospitalization(s):

Surgeries:

Current Medical Problems/Treatment:

Medications:

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 Gayle G. Anderson, M.A., PLPC
Supervisor: V. David Weiss, M.S., LPC
Client Information

Physicians:

Other:

Client/Guardian Signature: Date:

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