First Session Paperwork
Client Information Sheet
Michele Parsons, MA, MFT Intern IMF#54210 ___Private Pay _____VOC
Supervised by Amy Ellis, LMFT #MFC40536
(Last)___________________ (First) __________________ (Middle)_______ DOB:_________ Age:_____
Address:_________________________________________(city)_____________(zip)_______________
Phone Numbers: ( )_______________home; ( )_________________cell; ( )_______________other
Occupation:________________________________Average Monthly Income__________________________
School/Grade:_____________________________________________________________________________
___never married ____married ___divorced ___widowed ___coupled ___separated How Long?_______
List Current Medications:_____________________________________________________________________
Medical Concerns:__________________________________________________________________________
Name of Physician:_________________________Phone:___________________ Date of last physical:_______
Will you sign release:
Current Service Providers:__________________________________________________________________________ yes no
Any Past Service Providers Will you sign release:
(Therapists,psychiatrist, etc.):__________________________________________________________ yes no
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