Client Information | tgifcounseling

CLIENT INFORMATION

Please take a moment to fill out the form.

CLIENT NAME

DOB: required

Home Phone

Mobile Phone

Phone calls are treated with discretion. If you should have specific instructions please indicate below.

Employer / School

Employer Address

Referred by:

May I contact this person to thank them for the refferal?

YES

If referred by a clinician, would you like us to communicate with them?

YES

Emergancy Contact:

Phone

Contact will only be made if a life or death situation arises.

Yes, I understand and give my permission for TGIF Counseling to call my emergancy contact if such circumstances should arise

Please describe your presenting concern(s):

What are your goals for therapy?

How long do you expect to be in therapy in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)?

Thanks for submitting!