443.398.1700 | 443.952.0928
nina@thespacebetweentherapy.com
Fax: 443.279.2260
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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.