EmailMe Form - Northwest CIF

EmailMeForm

Counselor
Chart Number
Checked Photo ID
Chart Location
CONFIDENTIAL INFORMATION
Please fill out this confidential information form carefully and completely. This information will be used by your counselor to assist you.
CLIENT INFORMATION
Client Birth Date *
MM / DD / YYYY
Email *
Age *
Client Name *
First Middle Last Suffix
Preferred Name *
Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
County *
Home Phone
### - ### - ####
Work Phone *
### - ### - ####
Cell Phone *
### - ### - ####
CLIENT OR RESPONSIBLE PARTY
Employer Name
Your Occupation or Title
Employer Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Employer Email
Party responsible for payment, if other than client:
Name
First Last
Phone
### - ### - ####
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Race *
Ethnicity *
Annual Family Income *
less than 10,000
10,000-19,999
20,000-29,999
30,000-39,999
40,000-49,999
50,000-59,999
60,000-69,999
70,000-79,999
more than 80,000
Military Status
Active Duty
Retired
Reserve
Spouse
Family Member
Clergy Status
Active
Retired
Dependent
Spouse
Client Sex *
Marital Status *
Single
Engaged
Married
Separated
Divorced
Widow(er)
Denomination or Religious Preference
Local Church/Congregation
Education (select highest level completed) *
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Personal physician or group practice
Any allergies?
Current Medications
In emergency, please notify *
Phone *
### - ### - ####
Relationship *
Previous counselor or therapist
How did you hear about us? Check all that apply: *
Telephone Book
EAP Referral
Radio
Social Services
Yellow Pages
Physician
TV
Newspaper/Media
Attorney
Brochure
Minister
Former Client
School System
Friend/Family
Newsletter
Web Site
Insurance Company
Other*
*Other
Would you like to receive free mailings from the center?
YES
NO
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CONFIDENTIAL INFORMATION

CLIENT INFORMATION

CLIENT OR RESPONSIBLE PARTY

Party responsible for payment, if other than client: