Adult Client Information Form

This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.

The purpose of this form is to gather relevant information from persons who wish to receive services from Psychiatric Empowerment Services.

Fields marked with an asterisk (*) are required.

Today's Date

YYYY

Your legal name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your email address:

Date of Birth

YYYY

Gender

Would you like a text or email reminder for appointments?

If a text, who is your carrier? (Example: Verizon, T-Mobile)

EMERGENCY CONTACT INFORMATION

Contact name:

Relationship:

Telephone number (best):

(###)

###

####

Alternate telephone number:

(###)

###

####

Full address of Emergency Contact:

Your Primary Care Doctor:

Telephone number for Primary Care Doctor:

(###)

###

####

Psychiatrist:

If you do not have a psychiatrist, please indicate "none".

INSURANCE INFORMATION

Primary Insurance - Provide your Primary Insurance. If you do not have insurance, please indicate "none".

Insurance ID Number - Please provide your Insurance ID number. If none, please indicate "none".

Please provide the name of your insurance's Subscriber.

Who is your employer?

Please select one of the following:

I have a co-pay.

I have a deductible.

I will be paying the private pay rate.

Please indicate the amount of your co-pay or deductible. If you are a Private Pay client, please indicate "Private Pay".