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CRT COUNSELING-Change, Renewal, Transition, PA
CLINICAL INFORMATION SHEET

NAME:____________________

PHONE (H)

MESSAGES O.K.?

ADDRESS:_________________

(W)

MESSAGES O.K.?

(C)

MESS AGES O.K.?

CITY

ZIP

DOB:                                SS#:

INSURANCE:

 

SUBSCRIBER'S NAME: _______________________  SS#____________________________



HOUSEHOLD MEMBERS

NAME:

AGE

RELATIONSHIP

NAME:

AGE

RELATIONSHIP

NAME:

AGE

RELATIONSHIP

NAME:

AGE

RELATIONSHIP

EMPLOYER:

LENGTH OF EMPLOYMENT:                                              POSITION/TITLE:

ARE YOU CURRENTLY UNDER A PHYSICIAN'S CARE?______REASON:
NAME OF PHYSICIAN:______________________  PHONE #:____________________________

CURRENT MEDICATIONS:  _________________      PRESCRIBED FOR:____________________
................................................... _________________...................................... ____________________
...................................................._________________......................................____________________
....................................................._________________ .................................... ____________________

HAVE YOU EVER SOUGHT TREATMENT FOR SUBSTANCE ABUSE OR PERSONAL ISSUES BEFORE?____IF SO, PLEASE EXPLAIN:_______________________________

DO YOU CURRENTLY HAVE ANY LEGAL ACTION PENDING?____IF SO, PLEASE EXPLAIN:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

ARE YOU ON PROBATION/PAROLE?____IF SO, PLEASE EXPLAIN____________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
WHAT CHANGES DO YOU EXPECT FROM COUNSELING?_______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

IN CASE OF EMERGENCY PLEASE CONTACT:   _____________________PHONE #:___________

YOU ARE FINANCIALL Y RESPONSIBLE FOR ALL SCHEDULED APPOINTMENTS UNLESS A 24 HOUR CANCELLATION NOTICE IS GIVEN