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Isabel Mize
Heart Sage Academy
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CLIENT INFORMATION FORM
General Info:
Name:
Age:
Today's Date:
Month
Month
Day
Year
Referred by:
Address:
City:
State:
Zip:
Phone Number:
Email:
Emergency Contact (Name, Relationship to you, and phone):
Counseling Therapy History:
Have you been in counseling before?
Date begun:
Date ended:
Name of the therapist:
Location:
What brings you to therapy this time?
Goals for therapy:
Medical History:
Are you currently seeing a physician, health or mental health practitioner(s)?
If yes, please list name, title and phone number:
If yes, please list name, title and phone number:
Current Medication(s), dosage, length of time on med:
Past Medications:
How often do you use alcohol?
Drugs? Kind:
Significant history of alcohol/drug use or sobriety:
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