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:

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    Zip-Code:

    Emergency Contact/Responsible Party

    First Name:

    Last Name:

    Address:

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    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

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    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
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    Full Time Student
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    Unemployed/Seeking Employment
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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

    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.