INTAKE INFORMATION

CLIENT INFORMATION:

Name: Caregiver:   Relationship:

Address: City/State:   Zip: 

Phone: County:Sex: Male Female Race: DOB:Age:

SS# (Client):

Parent or Legal Guardian Information:

Name: Relationship: Phone:

Address: City/State: Zip:

Employment:

Employer: Contact: Phone:

Address: City/State: Zip:

FAMILY COMPOSITION (Who is living in the house with the client);

Name Relationship Age Other Information

Insurance Information:

Type of Insurance: Group Number:

Other I.D.: Insurance Contact # :

D.O.B. (of insured): S.S. # (of insured)

Insurance Phone Number

(Mental Health):