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Gamblers Counseling Center |
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Help to Get Started in Counseling |
Intake Form
Please "copy" this form and "paste" it to a word processor and complete it. Print it and bring it to your first session. Or you may print the form (from your browser window) and fill it out by hand. Please sign it at the bottom. Date: ____________ Name: ________________________________ Address: __________________________________ _______________________________________________________________________________ (City) (State) (Zip) Phone: Hm _________________ Wk ________________ Other ______________ E-Mail __________ Date of Birth ________________ Marital Status: _________________________________________ Who referred you?: ________________________________________________________________ Reasons you are here: _____________________________________________________________ ______________________________________________________________________________ Employer: ____________________________________ City, State:_________________________ Social Security Number: __________________________________________________________ Spouse’s Employer: ____________________________ City, State: _________________________ Prior Marriages (with dates): _______________________________________________________ OTHER PEOPLE LIVING WITH YOU (Name) (Birth Date) (Relationship) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ MEDICAL AND HEALTH INSURANCE INFORMATION Personal Physician: _____________________________________________________________ List any medications you are currently taking: __________________________________ Date Last Physical Exam. ___________________ Major Illnesses (in past) ____________ Previous Psychotherapy (yes/no): ____ If Yes, When and With Whom? ________________________ Primary Insurance Company: _______________________________________________________ Name of Insured: _________________________ Insurance Contact: ________________________ St. Address of Company: __________________________________________________________ City, State, Zip: _______________________________ Phone: ____________________ Insurance Group Number: ____________________________ ID Number: ___________________ Secondary Carrier: Write Same Information on the Back of this Form as you did for Primary Ins. Co. ------------------------------------------------------------------------------------------ I AGREE THAT CHARLES VORKOPER MAY MAIL NOTICES, NEWSLETTERS, AND OTHER PRINTED MATERIALS FROM HIS PRACTICE TO THE ADDRESS LISTED ABOVE: (Check one) Yes: __ No: __ Only to Alternate Address: __ (Address: ______________________) Signed: ________________________________________________ NOTE: Cancellation for individual sessions must be made 24 hours in advance of an appointment or the full be will be charged. |
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