Opticare Counseling, LLC 7439 Montgomery Road Suite 4 Cincinnati, OH 45236 (513) 570-4685 CLIENT REGISTRATION FORM Welcome to my practice. Please fill out the following questions as completely as possible. If you have any questions, please feel free to ask me when we meet. NAME: ____________________________________
BIRTHDATE: _____________________________
ADDRESS: _________________________________________________
AGE: _____________________
______________________________________________________ PHONE: _______________________ May I write to you there? YES / NO MARRIED
SINGLE
May I call you there? YES / NO
DIVORCED
SEPARATED
COHABITATING
If client is a minor, please list parent’s names________________________________________________ How did you find me?___________________________________________________________________ Employer: ______________________________________ Address: ______________________________ Insurance Plan: _____________________________ Policy Number:______________________________ Group Number: _____________________________ Please explain the reasons you are seeking counseling services at this time: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Have you ever attended counseling in the past? _____ If so, when? ____________________________ _____________________________________________________________________________________
How would you describe your health?
EXCELLENT
GOOD
FAIR
POOR
Please list any medications you currently take: ____________________________________________ __________________________________________________________________________________
Please circle any of the following which apply to you: Depression
Drug/Alcohol problems
Anger issues
Anorexia/Bulimia
Anxiety
Family problems
Grief
Abortion/Miscarriage
Stepfamily
Physical abuse
Adoption
Legal problems
Fighting
Sexual abuse
Stress
Self-esteem issues
Problems at work/school
Marriage/Relationship problems
Divorce
Health problems
Financial problems
Problems sleeping
Emergency Contact Information Name _________________________________
Relationship _______________________________
Phone number __________________________
Cell / Work phone ___________________________