New Client Basic Information

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Do we have your permission to send you mail for administrative purposes only, which may include Protected Health Information (PHI), such as vour name or your receipts for therapy sessions?

Yes or No

Can we call vou, and receive calls from you, at this number?

Yes or No

Do we have your permission to leave you a message to schedule an appointment that may include PHI, such as your name, our name/practice, and reason for the call?

Yes or No

Do we have your permission to send vou emails, or respond to emails from you, for the purpose of scheduling appointments, which may include PHI such as your name, our name, or therapy session dates?

Yes or No

Emergency Contact

First and Last Name/ Relationship to you

Contact Number

Preferred Local Hospital

Comments or instructions (including any special medical or personal information you would want an emergency care provider to known:

New Client Basic Information

Emergency Contact

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