Confidential Client Information

Before completing this form, please download and review the Counseling Policies and Procedures, Informed Consent and Release of Liability, and Notice of Privacy Practices.

First name

Today's Date

Sex

Last name

Date of Birth

Referred By

Address

Phone

Emergency Contact name

Emergency Contact Phone

Describe your relationship to your primary caregivers when you were a child:

Describe your current home and relationships to those you live with:

Describe your current relationship with God and the Church:

Describe why you’re seeking counseling at this time:

Describe what you hope to gain or change by coming for counseling:

Describe any previous counseling, psychiatric treatment, or residential/in-patient counseling:

Are you currently experiencing any suicidal or homicidal thoughts?

Yes

My signature below indicates that I grant informed consent for Dr. Andrew Graham to provide psychological services and counseling to myself and/or minor members of my family. I acknowledge having received the Counseling Policies and Procedures, Informed Consent, and Notice of Privacy Practices.

Type Name as Signature Here

Client Forms: Files