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Client Information

Sex
May we correspond with you at your home address?
OK to leave a detailed message?
OK to leave a detailed message?
OK to leave a detailed message?
Okay to email you?
Emergency Contact Information:
Medical History:
Have you ever received prior therapy?
Was therapy effective
Are you currently seeking counseling/therapy elsewhere?
Insurance Information:
Will you be using insurance?
Lifestyle Information:
Do you drink alcohol?
Do you use recreational drugs?
Patient Concerns:
Do you have concerns with life transitions?
Do you have cultural concerns?
Do you have concerns with stress and coping?
Do you have concerns with eating or appetite problems?
Do you have concerns with procrastination/motivation problems?
Do you have concerns with alcohol or drug problems?
Do you have concerns with depression, feeling blue?
Do you have identity concerns?
Do you have concerns with stress in the workplace/school?
Do you have concerns with money and budgeting problems?
Do you have concerns with relationships and/or marital concerns?
Do you have concerns with angry, hostile feelings?
Do you have concerns with friendship conflicts?
Do you have concerns with homicidal feelings or behaviors?
Do you have concerns with the loss of a significant person or grief?
Do you have concerns with self-esteem, self-confidence?
Do you have concerns with sleep problems?
Do you have concerns with loneliness, homesickness?
Do you have concerns with health problems?
Do you have sexual concerns?
Do you have concerns with a traumatic experience?
Do you have concerns with suicidal feelings or behaviors?
Do you have concerns with career/school choice or transition?
Do you have concerns with anxiety, nervousness, fears?
Do you have concerns with physical stress (headaches, stomach pains, muscle tension, etc.)?
Do you have concerns with physical/sexual abuse or rape?
Do you have concerns with family conflict, generational differences?
Do you have concerns with home management?
Do you have concerns with self-control or impulse control?

By signing, I authorize Currence Consulting, LLC to release/exchange any medical information with my insurance company in order to facilitate my treatment and payment. I authorize payment of health care/medical benefits to Currence Consulting.  I understand that I am financially responsible for any balance not covered by my insurance. Balances unpaid after 30 days are subject to a 1.5%/month finance charge, and I am responsible for any fees incurred if my outstanding balance is forwarded to a collection agency. I understand that if 24 hour notice is not provided when cancelling an appointment, I will be charged $75.00 for the reserved appointment time. Insurance companies will not pay this fee, so it will be my responsibility.  I understand that if I fail to show up for an appointment and do not follow up with my therapist within two weeks of the missed appointment, I am releasing my therapist from all liability associated with my psychological care/counseling.

Thank you for submitting your information!

Please list the members of your immediate family and other significant people in your life:

Patient Information:
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