Client Data Form and Consent for Care
Please submit one form for each person attending therapy with Keith Miller, LICSW
Name
*
First Name
Last Name
Name(s) of other individual(s) attending therapy with you:
Date of birth:
*
/
Month
/
Day
Year
Date
Occupation:
School/University (students):
City:
*
State:
*
Zip:
*
Cell:
*
E mail:
*
example@example.com
Emergency Contact Person:
*
Phone (home/cell):
*
Relationship to you
*
Name of General Practice Physician:
It is customary for me to inform the health practitioner of many of my clients that their patient is receiving treatment from me. May I contact your doctor for such purposes?
Yes
No
Phone # of your General Practice Physician:
From whom was I referred/recommended by?
May I send send you a newsletter with information about health and wellness? (I hate spam too and will respect your consent, which you may withdraw easily in the future.)
*
Yes
No
Authorization for Care
I, the undersigned, have received and read the Client-Clinician Agreement provided by Keith Miller, and I authorize him to provide the services of psychotherapy and/or counseling to me. I understand that the psychotherapy/counseling services provided to me are by appointment only and may not be available on an emergency basis.I consent to the charging of my credit card for the reservation of my appointment and understand that I will be charged for a full appointment after reserving it unless I contact Mr. Miller to cancel 24 hours beforehand.
Signature of Client
*
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: