Form #20, 21, 22      OFFICE INTAKE / CLIENT INFORMATION SHEET

NAME __________________________________________   DATE CASE________
ADDRESS _______________________________________________  ZIP ________
PHONE NUMBER ___________________________             REFERRAL SOURCE
D/O/B  _______________                                                         Directory
MARITAL STATUS  _______________                                   School
SPOUSE _________________________________________  Institution
CHILDREN/SIBS _______________________________        Court
AGES/SEX ____________________________________         Agency
OCCUPATION/EMPLOYER _________________________  Personal
EMPLOYER ADDRESS  _____________________________ Other
SPOUSE OCCUPATION/EMPLOYER ___________________________________
SPOUSE EMPLOYER ADDRESS _______________________________________
PRESENTING PROBLEM/CONCERNS __________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

REFERRING PHYSICIAN __________________  Address ______________ Phone
Primary Insurance CO __________________________________
Address ____________________________________________                       Phone
INSURED'S NAME ___________________________  Social Security # __________
SUBSCRIBER ID# _____________________  Group/file ______________________

EFFECTIVE DATE ______________________  Single / Family Coverage

SECONDARY INSURANCE CO ________________________________________
Address ____________________________________________                        Phone
INSURED'S NAME ___________________________  Social Security # __________
SUBSCRIBER ID# ______________________  Group/file _____________________

EFFECTIVE DATE ______________________  Single / Family Coverage

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FEE SCHEDULE

INTAKE/DIAGNOSTIC INTERVIEW             $120.00
INDIVIDUAL THERAPY                                  $120.00
INDIVIDUAL THERAPY                                  $60.00
FAMILY THERAPY                                          $120.00
GROUP THERAPY                                           $60.00/person
CONSULTATION                                            $120.00/negotiable
LATE (less than 24 hours) CANCEL                  $20.00