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New Client Information

Please print and fill out this form and mail or fax to Thalia.
Click here for contact information.
Forms are also available when you arrive for your appointment. Please plan to come early to allow time for this process if you choose this option.

Primary client's name:
Address (include city and zip)

Home phone (include area code if long distance from Kentwood):
Work phone (Is it OK to call here?)
Cell phone:
Email address:
Brief description of the problem:

How did you find out about Thalia's services?

Who should we contact in an emergency? (name)
Their home phone_______________Their work phone:___________________

Family Composition:
Client's father's name:                                  His age       His occupation
Client's mother's name:                                Her age      Her occupation
Are parents currently living together?*If not, why?
Siblings of client:
Name                                         Age               Where living?                        Occupation

Spouse of client                                             Age:      Date of marriage/cohabitation:
Client's previous marriages/parent of children:
Name                                Start Date         End Date               Reason ended

Client's children:
Name                             birthdate    age      Living with whom?          Parent's name

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