Client Basic Information Form

New Client Information

Sunshine State Serenity Counseling & Wellness Center
Client Name*

First NameLast Name
Client Gender*
Client Date of Birth*

MonthDayYear
Parent/Guardian Name (If Applicable)

First NameLast Name
Client E-Mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sexual Orientation*
Marital Status*

SingleMarriedSeperatedDivorcedWidowedOther
Reason for seeking therapy*
How did you hear about us?:*
Emergency Contact

Please list someone we may contact in case of an emergency
Relationship to contact*
Example: Mother, Father, Sibling, Aunt, Friend, Etc.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Financial Information

Who will be paying for your services
Who will be financially responsible for your services?*

MyselfSomeone else
If you chose someone else on the last question please fill out the questions below.
Relationship to client
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

New Client Information