Client Background Information

Please fill out the form below, read and check the red-highlighted "Policies and Procedures of CCA" link at the bottom of the form, and click "Submit Information." All fields are required, so please fill them out to the best of your ability. Estimate where necessary.

Please note that the contents of this form are transferred over a secure connection and are encrypted before they are sent to us. Your personal information will be kept confidential.

Personal
Insurance
Counseling and Medical
Referral and Other Contact
Faith Practice
Family

Personal Information

First Name:

Last Name:

Age:

Date of Birth:

Sex:

Home Address:

City:

State:

Zip Code:

Phone

Use between 9am and 3pm?

For confidential messages?

Home Phone:

Use between 9am and 3pm?

For confidential messages?

Work Phone:

Use between 9am and 3pm?

For confidential messages?

Mobile Phone:

Use between 9am and 3pm?

For confidential messages?

Days Available:

Times Available:

Mornings

Afternoons

Evenings

Email Address:

Employer: (or school attending)

Occupation:

How Long?

Highest Education Completed:

Telehealth?

Clinician Preference:

Insurance Information

Not all practitioners take insurance and there are two waitlists depending upon use of out-of-pocket or insurance. Please note all methods of payment you are able to use:

Out of Pocket

Insurance

Insurance Carrier:

Policy Holder's ID #:

Is Policy Holder Self?

Policy Holder's Name:

Policy Holder's DOB:

Policy Holder's Employer:

Counseling and Medical Information

Briefly describe the reason you are seeking counseling.

When did you begin to experience these difficulties?

Any previous psychological treatment or counseling?

Focus of Treatment:

Duration:

Therapist Name:

Phone:

Ending Date:

List any prescribed psychiatric medications:

Describe any current or recent medical treatment, including known allergies and medications:

Attending Physician:

Phone:

Fax:

Address:

City:

State:

Zip Code:

Date of Most Recent Physical Examination:

Current Height:

Current Weight:

Any Recent Weight Change (lbs):

Gained or Lost?

Referral and Other Contact Information

Referral Source Name:

Referrer:

Emergency Contact:

Phone:

Address:

City:

State:

Zip Code:

Faith Information

Affiliated with a local church?

Name of church and pastor:

Faith Practice Survey *derived from the Duke Religion Index

Please answer these 2 statements looking back at the past twelve months.

How often do you attend church, worship, or other religious meetings?

How often do you spend time in private faith activities, such as prayer, personal worship, or Bible study?

The following section contains 3 statements about religious belief or experience. Please mark the extent to which each statement is true or not true for you.

In my life, I experience the presence of the Divine (i.e., God).

My spiritual beliefs are what really lie behind my whole approach to life.

I try hard to carry my faith convictions over into all other dealings in life.

Family Information

Marital status:

Marital adjustment:

If married, how long?

If divorced, when?

Name of Spouse:

Spouse's Date of Birth:

Occupation of Spouse:

Living with Spouse?

Your Place of Birth:

List date(s) and duration of previous marriage(s):

If primary caregiver for anyone, list name(s) and relationship:

Please provide the following information concerning your family. (To provide information about each family member, please click the appropriate tab.)

Father
Mother
Brother (1)
Brother (2)
Brother (3)
Brother (4)
Sister (1)
Sister (2)
Sister (3)
Sister (4)

Father's Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Mother's Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Brother (1)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Brother (2)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Brother (3)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Brother (4)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Sister (1)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Sister (2)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Sister (3)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

Sister (4)'s Personal Information

First Name:

Age:

City of Residence:

If Deceased, Year/Cause:

Marital Status:

Occupation:

Rate Rapport:

List all your children from your present, or any previous marriages, giving the following information on each child. (Please list any deceased children and indicate age at death.):

Child (1)
Child (2)
Child (3)
Child (4)
Child (5)
Child (6)

Child (1)'s Personal Information

First Name:

Age:

Living with Whom?

If deceased, year/cause:

Child Of:

Occupation:

Rate Rapport:

Child (2)'s Personal Information

First Name:

Age:

Living with Whom?

If deceased, year/cause:

Child Of:

Occupation:

Rate Rapport:

Child (3)'s Personal Information

First Name:

Age:

Living with Whom?

If deceased, year/cause:

Child Of:

Occupation:

Rate Rapport:

Child (4)'s Personal Information

First Name:

Age:

Living with Whom?

If deceased, year/cause:

Child Of:

Occupation:

Rate Rapport:

Child (5)'s Personal Information

First Name:

Age:

Living with Whom?

If deceased, year/cause:

Child Of:

Occupation:

Rate Rapport:

Child (6)'s Personal Information

First Name:

Age:

Living with Whom?

If deceased, year/cause:

Child Of:

Occupation:

Rate Rapport:

It is important to the success of your counseling that you understand, consent to and cooperate with these professional guidelines. After you read it, we suggest you print this document to keep for future reference.

I have read and agree to the Policies and Procedures of CCA.

Three things will last forever - faith, hope, and love.

I Corinthians 13:13