Counseling Center | Milford, NH | Family Guidance Center

Family Guidance Center of Milford

Client Intake Form

Client Intake

Name:

Date of Birth:

SS #

Marital Status:

Spouse’s Name (if applicable):

Referred By:

Address:

City:

State:

Zip:

Home Phone:

Is it okay to leave a message?

Yes

Cell Phone:

Is it okay to leave a message?

Yes

Free Text

Parent/Guardian Information:

Parent/Guardian Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

Parent/Guardian 2 Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

Free Text

Emergency Contact - this person will be contacted in the case of an emergency

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Free Text

Primary Care Physician

Name/Practice:

Phone

Address:

City:

State:

Zip:

Do we have your permission to coordinate care with your Primary Care Physician?

Yes

Free Text

Client Employer

Employer Name:

Phone

Address:

City:

State:

Zip:

Free Text

Insurance Information

Primary Insurance Company:

Policy #:

Policy Holder:

Relationship:

Secondary Insurance Company:

Policy #:

Policy Holder:

Relationship:

Free Text

Emailed Invoices (optional)

Billing invoices are available by email. Please be aware that although unlikely, communications via email may be lost,

delayed, intercepted, delivered to the wrong address, or arrive incomplete or corrupted. If you understand and accept

responsibility for these risks please provide your signature and email address below.

Email:

Family Guidance Center of Milford

Client Intake Form

Client Intake

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