Name:_____________________________________________________________________________________

Address:___________________________________________________________________________________

__________________________________________________________________________________________

Telephone: ______________________________              Fax:________________________________________

Cell : ___________________________________              Work Telephone:______________________________

Date of Birth: _____________________________              Age: _______________________________________

Social Security No.: _____________________________

Email:_____________________________________________________________________________________

Marital Status:  ___________________________       Spouse's Name:  _________________________________

Employer:  _________________________________________________________________________________

EMERGENCY CONTACT:

Name: ____________________________________________________________________________________

Telephone: ________________________________________________________________________________

Are you currently under the care of a Physician?       Y      N

Do you have any chronic or ongoing medical conditions:       Y      N

If so, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

What medications are you taking (include over-the-counter medications):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

DOCTOR'S INFORMATION:

Name:  _______________________________________         Telephone:  ______________________________

Person who referred you:

Name:  _______________________________________         Telephone:  ______________________________

Insured by:

Name:  _______________________________________         Telephone:  ______________________________

Policy #:  _____________________________________          Group #:  ________________________________

CLIENT INFORMATION:

Prior psychological or chemical dependency counseling/treatment:      Y      N

If so, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Nature of presenting problem?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Alcohol or drug use?     Y      N

Tobacco?      Y      NCaffeine?      Y      N

CONSENT FOR EVALUATION:

I hereby agree to the performance of an interview and the collection of information deemed necessary by Lois Thomson-Bowersock, LCDC, ADC II, CET, to evaluate my problems/needs and make appropriate recommendations.

________________________________________________
Client Signature

Date:  __________________________________________

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