9085 East Mineral Circle | Suite 235 | Centennial, Colorado 80112 | Phone 720.299.8342 | Email

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Client Name:_____________________________________Today’s Date:____________

Name of Guardian(s) (if client is a minor):_____________________________________

Address:_______________________________________________________________

City, State, Zip:__________________________________________________________

Gender:__________ DOB:____________ Age:_______  SSN:____________________

Relationship Status:    single    married    domestic partner    separated    divorced     widowed 

Occupation/Work Emphasis:_______________________________________________

Home Phone:___________________________ Okay to contact you there?_________
                                                                    Okay to leave a message?__________

Work Phone:____________________________ Okay to contact you there?________
                                                                     Okay to leave a message?_________

Cell Phone:_____________________________ Okay to contact you there?_________
                                                                     Okay to leave a message?_________

Referred By:_____________________________________________________________

Emergency Contact Name:___________________________ Phone:________________

Relationship to you:_____________Okay to contact in the event of an emergency?___

Please list other people living in your household and their relationship to you: 

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Primary Insurance Information:

Insured Name:__________________________________________________________

Insured DOB:______________________ Insured SSN:_________________________

Insured Employer:_______________________________________________________

Payer/Health Plan:_______________________________________________________

Your Relationship to Insured:     self     spouse     dependent

Member Number:___________________ Policy/Group Number:___________________

Secondary Insurance Information:

Insured Name:__________________________________________________________

Insured DOB:______________________ Insured SSN:__________________________

Insured Employer:________________________________________________________

Payer/Health Plan:_______________________________________________________

Your Relationship to Insured:     self     spouse     dependent

Member Number:___________________ Policy/Group Number:___________________

Please present insurance card(s) to me, so that I can make a copy.

Please describe your reason(s) for seeking treatment at this time. If there is a particular event that triggered your decision to seek treatment now, please list the event:___________________________________ 

_____________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life:
 

.
No Effect
Little Effect
Some Effect
Much Effect
Significant Effect
Not Applicable
Relationship . . . . . .
Family . . . . . .
Job/School . . . . . .
Friendships . . . . . .
Finances . . . . . .
Physical Health . . . . . .
Anxiety Level . . . . . .
Mood . . . . . .
Eating Habits . . . . . .
Sleeping Habits . . . . . .
Alcohol/Drug Use .. . . . . .
Sexual Functioning .. . . . . .
Ability to Control Anger .. . . . . .

What result(s) do you expect from treatment: ________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
 

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Colorado Licensed Clinical Psychologist License #2741.  © Copyright 2006-2018 by Dr. Jennifer Ritchie-Goodline.  All Rights Reserved.

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