409.220.3067 | 443.398.1700 nina@thespacebetweentherapy.com 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:
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 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
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Jail/Correctional Facility
Homeless Shelter
Other

Employment Status:

Full Time Employed
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Full Time Student
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Race: (check all that apply)

White
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Ethnicity: (check one)

Hispanic
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Marital Status: (check one)

Single
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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

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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.