409.220.3067 | 443.398.1700 [email protected] PAYMENT
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All efforts to maintain your privacy are taken, however, this form is not encrypted, as our online forms are offered as a convenience.  Please feel free to print out and email, or drop off your completed form in-person, if you prefer.

    Client Information Sheet
    First Name:
    		 Last Name:
    Date of Birth:
    		 Age:
    Address:
    		 City:
    State:
    		 Zip-Code:

    Emergency Contact/Responsible Party
    First Name:

    		 Last Name:
    Address:
    		 City:
    State:
    		 Zip-Code:
    Relationship:
    		 Telephone:

    Contact Information
    Mobile Phone:
    		 Can we text your appointment reminders?
    YesNo
    Home Phone:
    		 Can we leave messages?
    YesNo
    Work Phone:
    		 Can we leave messages?
    YesNo
    Email:
    		 Can we send messages?
    YesNo
    Preferred contact method: MobileHomeWorkEmail
    How did you hear about us?

    Employer

    Company
    		 Position

    Primary Care Physician

    Physician Name:

    		 Telephone:
    Address:
    		 City:
    State:
    		 Zip-Code:
    Please list any medications you are currently taking:
    		 Please list any food or drug allergies:

    Additional Client Information

    Living Situation: (check one)

    Private Residence
    Foster Care
    Residential Care
    Crisis Residence
    Institutional Setting
    Jail/Correctional Facility
    Homeless Shelter
    Other

    Employment Status:

    Full Time Employed
    Part Time Employed
    Full Time Student
    Part Time Student
    Unemployed/Seeking Employment
    Not Seeking Employment
    Unemployed/Disabled
    Retired

    Race: (check all that apply)

    White
    American Indian or Alaskan Native
    Black or African American
    Asian
    Native Hawaiian or Other Pacific Islander

    Ethnicity: (check one)

    Hispanic
    Non-Hispanic

    Marital Status: (check one)

    Single
    Married
    Separated
    Divorced
    Widowed

    Highest Level of Education Completed:
    Are you a hurricane victim?

    YesNo

    Are you a veteran?

    YesNo
    If yes, of which war?
    Number of arrests within the past 30 days?
    What is your primary language?


    Do you speak any other languages?
    YesNo
    If yes, which languages?
    Do you have difficulty hearing?

    YesNo

    Do you have serious difficulty seeing i.e. wearing glasses or contacts?

    YesNo

    Upload your Insurance Card (Please upload both front and back):
    AUTHORIZATION
    By selecting the Submit button I certify that the information I have provided in this online form is true and complete to the best of my knowledge. The Space Between will not use my information, nor share my information with any other organization without my knowledge or written consent.