South Shore Counseling | Mental Health Therapy in Wisconsin

Client Information

Client Name*

Date*

Date of Birth*

Social Security Number*

Gender Identification

Parent/Guardian/Legal Representative

Custody of Child

Yes

No

Contact Information

Address*

Apt/Suite

City

State

Zip Code

Primary Phone #1

Phone #2

Background

Occupation

Employer

Reason for Seeking Counseling

Medical Problems

Current Medications

Personal Information

Marital Status

For How Long

Partner’s Name

Religious Affiliation

Race/Ethnicity/Tribe

Nation of Origin

Length of Time in US (years)

Previous Counseling

Previously Seen By

Psychiatrist

Psychologist

Counselor

Therapist

List Names and Dates

Insurance Information

Insurance Company

Policy ID

Group #

Policy Holder

Policy Holder DOB

Policy Holder SSN

Relationship to Client

Referral & Emergency

Emergency Contact Name and Phone Number

Who Referred You?

Client Registration Form