Client Name *
Client Name
DOB *
DOB
Gender
Phone Number, Cell
Phone Number, Cell
Other
Other
Ok to call both? *
Address
Address
Race/Ethnicity *
Marital Status
Work Address
Work Address
Work Phone Number
Work Phone Number
$
$
How did you hear about Airport Marina Counseling Service (AMCS)?
Have you ever had prior counseling, therapy, or psychiatric care?
Have you ever been hospitalized for psychiatric care?
Date of Last Hospitalization?
Date of Last Hospitalization?
Have you ever received counseling (individual, couples, family, or group) at AMCS before?
Have you ever received PSYCHIATRIC services (medications) at AMCS before?
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?
Do you have psychiatric coverage?
Are you a Veteran?
If yes, do you have VA Benefits?
Doctor's Info
Doctor's Phone
Doctor's Phone
Date of Last Visit
Date of Last Visit
Probation Information
Are you currently on probation?