Get Client Demographic Form - Alliance Counseling And Education

Filling out the Client Demographic Form is an essential step in starting your counseling journey. This guide provides detailed instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete your Client Demographic Form with ease.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by entering today's date at the relevant section. This helps to establish a timeline for your records.
3. Provide your therapist's name, which may be pre-filled for you. If not, enter 'Kim England, LCSW' as indicated.
4. Fill out the client information section with your full name and marital status. Ensure that you indicate if the name provided is your legal name.
5. Enter your date of birth and age in the designated fields. Select your sex from the options provided.
6. In the address section, fill in your street address, city, state, and zip code accurately. Provide your social security number and driver’s license number as requested.
7. Input your occupation and employer's name, then add your home phone number, cell phone number, and email address.
8. Indicate how you were referred to the provider by filling out the appropriate section.
9. If applicable, complete the legal involvement section by providing the attorney's name, contact details, and indicate if an Ad Litem or Ambicus Attorney is involved.
10. For the contact authorization, select a preferred contact method for your therapist and whether they can leave messages with a partner.
11. Complete the service you are seeking section by checking the relevant boxes for individual, couples, or family counseling.
12. Fill out the guarantor's information if different from yours, including their relationship to you.
13. Provide emergency contact details, including name, relationship, and phone numbers.
14. Complete the primary and secondary insurance sections, including all relevant policy and subscriber information.
15. Finally, read and agree to the information provided regarding consent for treatment. Sign and date the form as required.
16. Once all sections are completed, save the changes to the form. You may have the option to download, print, or share the completed form.

Act now and complete your Client Demographic Form online for a smooth start to your counseling experience.