New Client Information (page 2)

Employer of client (or parent if client is a child):
How long employed there?
Employer of spouse/partner:
How long?

Does client have any health problems or take any medications? Please describe.


Does  the client and/or parent (if client is a child) have any current legal involvement , including probation or parole? Any in the past? please describe.

Has the client had any previous counseling?      When?    
By whom/where?                    Reason for counseling:

Name of person filling out this form:

Today's date:

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