Client Demographics "*" indicates required fields Client StatusActiveMed OnlyInactiveDischarged - DNCClient InformationPreferred Name Legal First* Legal Last* DOB* MM slash DD slash YYYY Gender*MaleFemaleOtherMarital Status*SingleIn a RelationshipEngagedMarriedRemarriedSeparatedDivorcedWidowedPrimary Office*Choose OneBay CityGrosse PointeMidlandMount ClemensPort HuronSaginawPrimary ProviderAdd list of providersParent / Guardian InformationLegal First* Legal Last* Mobile Phone*Email* Communication & SchedulingMobile Phone*Email* Home PhoneHome Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What's the best way to contact you? Text Call Email Mail How would you like to receive appt reminders? Text Call Email No Reminders Can we leave a voicemail?YesNoWill you be using telehealth services?Yes, consented.No, declined.Do you want to allow anyone access to your account and billing information on your behalf?YesNoWho would you like to add? This person will be able to make changes to payments and appts. Screening QuestionsAvailability: What days and times work best for your appointment times? Dual Relationship: Do you currently have a local church you attend? If yes, what's the name?* Presenting Problems: Can you give me a brief description to why you decided to pursue counseling? Psychotropic Medications: Are there any medications you are currently taking for mental health and/or ADHD? Inpatient Hospitalization: Have you ever been hospitalized before for mental health reasons? If so, when was the latest time and where? Substance Abuse Related: Do you have any current or past use/abuse of substances such as alcohol, drugs, marijuana, or prescription medication? SSI Benefits/Med Seeking: Would you say that one of your primary reasons for seeking treatment is because you are court ordered, related to obtaining SSI benefits, or obtaining medications that are controlled substances? How did you hear about us?*Friend / FamilyCurrent / Former ClientPrimary Care DoctorChurch/PastorRenewal WebsitePsychology TodayGoogleFacebookRadioHospitalOtherWho referred you? Reading Support Preferred*NoYesComments: EmailThis field is for validation purposes and should be left unchanged. Copyright 2020 © Renewal Christian Counseling Center
