Client Demographic Form "*" indicates required fields Step 1 of 3 33% EmailThis field is for validation purposes and should be left unchanged.Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DL NumberDL NumberDate of Birth Month Day Year Date of BirthAgeAgeSocial Security NumberSocial Security NumberHome Phone*Home PhoneWork PhoneWork PhoneCell PhoneCell PhoneOtherOtherBest Number to Reach you Home Work Cell Phone Other Select Best Number to Reach YouEmail* Email AddressResponsible Party*Responsible PartyRelationshipResponsible Party Relationship to patientResponsible Party DOB Month Day Year Responsible Party DOBResponsible Party DLResponsible Party DLResponsible Party PhoneResponsible Party PhoneResponsible Party Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Enter Responsible Party address if different from aboveEmployerEmployerWork PhoneWork PhoneMay We Call There? Yes No May We Call There?Emergency Contact*Emergency ContactRelationshipRelationshipPhonePhoneReferred By:Referred By: Payments Due* I agree*All Payments are due at the time of service. If, for any reason, payment is not received at time of service, client will be allowed five (5) business days to make payment in full unless other arrangements are made. I understand that payment due is based on United Hands Counseling & Consulting’s best estimate. I understand I am responsible for any fees not covered by the insurance plan. If the debt is not paid, it will be sent to collections. Initials*InitialsReturned Payments* I agree*Returned checks require a $25.00 per check charge in addition to payment of Fees accrued. Initials*InitialsCancellations* I agree*This office MUST be contacted at least 23.5 HOURS PRIOR to appointment to avoid MISSED APPOINTMENT CHARGE. Initials*InitialsFee Schedule* I agree* Individual Psychotherapy, Parent/Family Conference Therapy 30 Minutes…………………………………..$65.00 1 Hour (53 Min.) if payment not received at time of service………….....………………………………………$120.00 1 Hour (53 Min.) if payment received at time of service…………………………………………………….$120.00 Missed Appointments ...........................................................................................................................$120.00 Brief Phone Calls ...................................................................................................................................No Charge Phone Consult (over 15 Minutes)......................................................................................................Based on Hourly Rate Outgoing Correspondence re: evaluation or treatment of a client ½ page or less .............................No Charge Comprehensive summaries, evaluations, letters, or reports .........................................................Based on Hourly Rate On site observations, staffing, follow up conferences, court (includes travel time)............................$135.00 Insurance Accepted....Contact our office for more information on accepted insurance Occupation/SchoolOccupation/SchoolNumber of YearsNumber of YearsEducation: Highest Level CompletedEducation: Highest Level CompletedAny DegreesAny DegreesMajorMajorMarital Status Single Married Partnered Separated Divorced Widowed Cohabitating Marital Status (Choose One)If ever married, how many times?If ever married, how many times?If ever divorced, how many times?If ever divorced, how many times?Place you live in (Select One): Home Apartment Condo Room Hotel Other Place you live in (Select One):Family PhysicianFamily PhysicianPhysician PhonePhysician PhoneMedications Currently TakingMedications Currently TakingAny Medical Conditions?Any Medical Conditions?What brings you here today/Reason for Referral:*What brings you here today/Reason for Referral:**CONSENT FOR TREATMENT** I agreeI hereby authorize this therapist to evaluate and render appropriate counseling service to myself/my child. This consent is knowingly and freely given. I further understand that ALL INFORMATION given by myself/my child or any member of my family to the therapist is CONFIDENTIAL and WILL NOT be released except by WRITTEN client permission or as provided by law. I understand the Office Policies as stated above and accept full responsibility for payment of services rendered. SignatureClient (or Parent, if Client is a Minor)
