Client Demographic Sheet
Counseling Within Reach, PLLC
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Communication Preferences (Check all that apply. If you have any special requests, please describe in 'other' section).
Phone / voicemail
Email
Secure messaging: Requires download of Spruce Health app
Mail
Communication Exclusions (check if you do not want to be contacted by these methods)
Phone / voicemail
Email
Secure messaging: Requires download of Spruce Health app
Mail
Emergency Contact
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Presenting Concerns
Briefly describe what brings you to therapy.
Submit
Should be Empty: