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About
About
Board of Directors
Management
Our Services
What We Do
Group Therapy/Classes
LGBTQIA+ CENTER
2025 Spring Celebration Recap
Mary Ellen Cassman Tribute
Join Our Team
Training Information
Employment Opportunities
Volunteer Opportunities
Donate
Planned Giving
Donate Today
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Amazon Smile
Previous Fundraisers
Guild Events
News
Contact Us
Home
About
About
Board of Directors
Management
Our Services
What We Do
Group Therapy/Classes
LGBTQIA+ CENTER
2025 Spring Celebration Recap
Mary Ellen Cassman Tribute
Join Our Team
Training Information
Employment Opportunities
Volunteer Opportunities
Donate
Planned Giving
Donate Today
AMCS Angels
Amazon Smile
Previous Fundraisers
Guild Events
News
Contact Us
Client Name
*
First Name
Last Name
DOB
*
MM
DD
YYYY
Gender
M
F
Other
Phone Number, Cell
(###)
###
####
Other
(###)
###
####
Ok to call both?
*
Yes
No
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Race/Ethnicity
*
Asian/Asian American
Black/African American
White/Caucasian
Hispanic/Latino/Latina
Filipino
American Indian
Pacific Islander
Other Non-White
Mixed Race/Ethnicity
Marital Status
Single or Never Married
Married Now
Divorced
Widowed
Separated
Living With
# of People Living in Household
# of Minors/Dependents in Household (dependent on you)
Occupation
Work Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Phone Number
(###)
###
####
If Unemployed, Source of Income
Client's Monthly Gross Income
$
Household Monthly Gross Income (include all income)
$
Years of School Completed or Current Grade
If Attending School Now, Name of School
How did you hear about Airport Marina Counseling Service (AMCS)?
Friend/Family
Doctor/Nurse
Other Clinic or Agency
Another AMCS Client
Mental Health Professional
Boys & Girls Club
Internet
Church/Synagogue/Temple
DiDi Hirsch
Phone Book
School
Edelman
Drove Past/Live Nearby
Court/DCFS
YMCA
Other
What concerns brought you to Airport Marina Counseling Service (AMCS)?
Have you ever had prior counseling, therapy, or psychiatric care?
Yes
No
Have you ever been hospitalized for psychiatric care?
Yes
No
How many times?
Date of Last Hospitalization?
MM
DD
YYYY
Have you ever received counseling (individual, couples, family, or group) at AMCS before?
Yes
No
Have you ever received PSYCHIATRIC services (medications) at AMCS before?
Yes
No
To Determine if your health insurance will cover services at AMCS, a copy if your insurance card must be submitted.
Do you have medical insurance?
Yes
No
Do you have psychiatric coverage?
Yes
No
Unsure
Name of insurance company
Are you a Veteran?
Yes
No
If yes, do you have VA Benefits?
Yes
No
Doctor's Info
Dr's Name
Doctor's Phone
(###)
###
####
Date of Last Visit
MM
DD
YYYY
Please list current medications, recent serious illness or new health concerns
Probation Information
Are you currently on probation?
Yes
No
Thank you!
