1821 University Avenue W. Ste S303

Client Forms


 

                   Take Flight Counseling Services,LLC.

                                                                                                            1821 University Avenue Suite#S303

                                                                                                                      Saint Paul, MN 55104

                                                                                                                      Phone: 612-554-9661


                                                                         Required Client Information

 

Date: _____________________________________ Clinician Name: _________________________________________

 

Who referred you? __________________________________________________________________________________

 

Reason for this appointment: __Therapy  __Medication  ___Intake  ___Evaluation/Assessment ___Other: ____________

 

Client Name: _______________________________________________________                 __Male __Female

 

Race: __African-American American __ Indian/Alaska Native __Asian __Caucasian __Hispanic/Latino __Native Hawaiian __or other Pacific Islander  ___Other: __

 

Date of Birth: _______/_____/___________                             SS#: _________-_______-_________

 

Marital Status: __Single   __Married   __Widowed   __Divorced  __ Separated   __Other __________

 

Address: _____________________________________________________________________________________________

 

City: ___________________________________________State: ____________ Zip: ________________________________

 

Residence Type: __House   __ Apartment   __ Room    __Group Home    __Other: ___________________________________

 

Home #: ___________________________ Work #: ________________________ Cell #: _____________________________

Please leave messages at:    ___Home    ___Work    ___Cell

 

E-mail Address: ________________________________________________________________________________________

Appointment reminders are done via e-mail.

 

 

Emergency Contact Name: _____________________________ Emergency Contact Phone: ____________________________

Primary Care Clinic & Physician: __________________________________________________________________________

Clinic Phone #: ___________________________________Clinic Fax #: ___________________________________________

Current/Past Drug Prescriptions: __________________________________________________________________________

___________________________________________________________________________________________________

 

MEDICAL /INSURANCE  INFORMATION – Name and Phone #:________________________________________________

1st INSURANCE CARRIER: ______________________________2nd INSURANCE CARRIER: ________________________

Policy Holder Name: _____________________________________ Policy Holder Name: _____________________________

Policy Holder’s DOB: ____________________________________ Policy Holder’s DOB: ____________________________

ID#: _________________________________________________   ID #: ________________________________________

GROUP #: ____________________________________________   GROUP #: _____________________________________

EMPLOYER: __________________________________________  EMPLOYER: ____________________________________

 

                       All co-payments, co-insurances, deductibles, and balances are due at the time of your appointment