Member intake

Member Intake

Name (legal name of person being seen):

Email:

Date of Birth:

Age:

Today's Date:

Client Demographics

Gender:

MaleFemale

Marital Status:

SingleMarriedWidowedDivorcedSeparated

Race:

AsianBlack or African AmericanWhite or Caucasian / Euro AmericanNative AmericanMid EasternLatinoNative Hawaiian / Pacific IslanderOther:

Veteran:

YesNo

Address:

City:

State:

—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP:

Phone:

Legal guardian:

SelfOther:

School & grade or Occupation:

Consent for Treatment

I authorize the evaluation and/or treatments of the client identified above and agree to pay all charges for the evaluation and/or treatment provided.

Consent for Emergency Care

I consent to Emergency Medical Care: This is to authorize Psychological Mobile Services, PA to seek emergency medical care if needed. It is understood and agreed that the staff and Psychological Mobile Services, PA will be held harmless for any and all results of the staff’s efforts to obtain emergency medical treatment including any accident or injury while being transported.

In case of emergency contact

Name:

Relationship:

Number:

Δ