Name 	__________________DOB: ________Age:_____ Sex: ____ Race: __________
Parent/guardian name (if child)______________________________________________
Home Address/zip: ________________________________________________________
Phone: (H)_____________________________(C)_______________________________
School or Work
Name: __________________________________________________________________
Address: ________________________________________________________________
Phone: _________________________________________________________________
Other Care Providers:
Name:_______________________________Phone:______________________________
Medications:
Name: _________________ Dose: ________________ Prescribed By: _____________
Name: _________________ Dose: ________________ Prescribed By: _____________
Insurance (if applicable)
Name of Insured: _______________________ Date of Birth: ______________________
Address: ________________________________________________________________
Phone: _________________________________________________________________
Company: ______________________________________________________________
Group #: ________________________ID#: ____________________________________
Type of Mental Health coverage (deductibles, co pays, # of visits per year etc):
________________________________________________________________________________________________________________________________________________