Kim's new client form

Kim's New Client Form

Client Information

Name *

First

Last

Email *

Primary Phone Number *

Alternate Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Social Security Number *

If married, how long? *

Employer *

Employer Address *

Line 1

Line 2

City

State

Zip Code

Country

Work Phone Number *

Can we call you at work? *

Yes No

Person Financially Responsible *

Relationship *

Social Security Number *

Date of Birth *

Address if different *

Line 1

Line 2

City

State

Zip Code

Country

Name of Spouse/Parents/Guardians *

Emergency Contact and Relationship *

Emergency Contact Phone *

Children/Siblings in Household *

Names/Sex/Ages *

Number of Children in Family of Origin *

Sibling position in family of Origin *

Medication you are presently on *

Physician *

Physician Phone Number *

Date of Birth *

Occupation *

I agree to inform Kim Mayes-Kessell, MA & Northwest Family Counseling Services if any information changes on this form. I understand that I am responsible for all charges for services provided, including late, cancellation (less than 24 hours notice) and no-show fees. I understand that I will be held additionally responsible for all collection and attorney fees necessary to collect fees owed. I understand that payments need to be made at the time of service and that additional billing charges and statement fees may be added to payments not made at the time of service.

By checking this box I agree with the statement above. *

Yes I agree

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