Samaritan Counseling Center of Southern Wisconsin
5900 Monona Drive, Suite 100 Monona WI, 53716
NEW CLIENT INFORMATION
Please complete this form as completely as you can. All information will be held in strict confidence.
Today's Date__________________________
Referral
How did you learn about our services?
____________________________________________
If you were referred, by whom? _________________________________________________
Personal
Name
____________________________________________________________________
Last
First
Middle
Initial
Address
___________________________________________________________________
Street
and
Number
City
State
Zip
Phone (Home) _________________________
(Work) ____________________________
Sex _____
Date of Birth _______________________
Soc. Sec. # ____________________
Employer
__________________________________________________________________
Employer's Address __________________________________________________________
Family
Married _______
Single
______
Widowed _______
Divorced _______
Separated _______
Name of Spouse ___________________________________ Date of Birth
______________
(Address if different from above)
________________________________________________
Spouse's Soc. Sec. # ______________
Employer of Spouse
__________________________________________________________
Employer's Address
__________________________________________________________
Family History
All immediate family members (mother, father, siblings, partner/spouse,
and children if applicable)
Name ______________ Sex ____ Age _____ Lives with you ____ Lives
outside of house
____
Name ______________ Sex ____ Age _____ Lives with you ____ Lives
outside of house
____
Name ______________ Sex ____ Age _____ Lives with you ____ Lives
outside of house
____
Name ______________ Sex ____ Age _____ Lives with you ____ Lives
outside of house
____
Name ______________ Sex ____ Age _____ Lives with you ____ Lives
outside of house
____
Name ______________ Sex ____ Age _____ Lives with you ____ Lives
outside of house
____
Have any children died?
_______________________________________________________
Professional
Have you previously had counseling? ______________
With whom? _____________________
Where? ____________________________________
Why? _________________________
Are you currently receiving counseling, therapy, or other mental health
services elsewhere?
_____
If YES, provider's name _________________
Location ____________ Duration ___________
Medical
Who is your Primary Medical Provider?
___________________________________________
Do you have any current, recurring, or chronic medical concerns? Yes
____
No ____
If YES please describe
____________________________________________________
Are you presently taking medications? Yes___
No ___
If YES please list medication and condition it is taken for.
Medication
______________________ Condition
______________________________
Medication ______________________ Condition
______________________________
Medication
______________________ Condition
______________________________
Do you have any allergic reactions to medications? Yes
___ No ___
If YES, please describe:
___________________________________________________
Do you have a disability that limits your activity in any way? Yes
____ No ____
If YES, please indicate nature of the disability:
_______________________________________
Payment
Do you plan to use your health insurance for your counseling services?
Yes ____
No ____
If YES please give therapist your insurance card( s) so a copy of the
front and back may be taken.
Do you have other funding sources that will pay for counseling services?
Yes
____ No ____
If so, what are they?
__________________________________________________________
Faith
Which church, if any, do you worship regularly
at?____________________________________
Who is your pastor?
__________________________________________________________
Do you wish to have your faith be part of the counseling process?
________________________
Assignment of Benefits
I hereby authorize the my insurance company( s) to make payment directly
to the provider for the benefits herein and otherwise payable to me. I
authorize for the release of any medical information necessary to
process my insurance claims.
Signature _______________________________________________
Date ______________
Print and complete this form when you come to your first counseling session.