701-261-4472
Mon-Sat
9:00 AM - 4:00PM
Appt Only

Client Info. Form

Name:

Email:

D.O.B.

Address: Street Address

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Reason for services?

Sex:

Race:

Veteran:

Yes

Married:

Yes

How did you hear about this counseling service?

Who referred you to this counseling service?

What circumstances brought you here:

Are you currently seeing anyone for mental health issues?

Who are you seeing?

What medication, if any, do you take?

Do you have any health problems?

Do you have any present legal charges?

Please read and date the following:
I understand that the payment of these services is my responsibility at the time of service.

Client Signature:

Date:

Parent/Guardian Signature:

Date: