NEW CLIENT REGISTRATION
Dykstra Counseling, LLC
Wayne Dykstra, PhD, MA, LMHC
(206) 399-5776
Demographic Information
Today’s Date: ______________________
Name of Client: ____________________________ Age: ________ Gender(s): __________
Mailing Address:
___________________________________________________________________________
Email Address: _______________________________________________________________
Date of Birth: ________________________________________________________________
Home Phone: ______________________May I Call This Number? Y N Leave a Message? Y N
Cell Phone: _______________________ May I Call This Number? Y N Leave a Message? Y N
Person Responsible for Bill: ____________________________________________________
Relationship:
__________________________________________________________________
Address:
______________________________________________________________________
Phone:
________________________________________________________________________
Email:
_________________________________________________________________________
CLIENT EMPLOYER INFORMATION
Employer: ___________________________________________________________________
Occupation: __________________________________________________________________
Address:_____________________________________________________________________
Work Phone: ___________________ May I Call This Number? Y N Leave a Message? Y N
CLIENT SCHOOL INFORMATION
Name of School: ______________________________
Current Grade Level: ___________________ Average Grade Point: ______________
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INSURANCE INFORMATION
Name of Insured: ______________________ Date of Birth: ____________________________
Primary Insurance Company: ____________________________________________________
Address: ________________________________________ Phone: _____________________
Subscriber/ID #: _____________________ Group #: _________________________________
Secondary Insurance Company:
Name of Insured: ____________________________________________________________
Social Security#:___________________________ DOB: ____________________________
Address: ____________________________________________________________________
Phone: _____________________________________________________________________
Subscriber/ID #: _______________________ Group #: _____________________________
PHYSICIAN & REFERRAL INFORMATION
Name of Physician: __________________________ Phone:____________________________
Name of Therapist/Counselor: _________________ Phone: __________________________
Who referred you to our office? _______________ Relationship: _____________________
MEMBERS OF THE HOUSEHOLD
Name
Relationship to Client
Age
Gender Identity
PERSONAL INFORMATION
Sexual Orientation(s):___________________________________________________________
Religious/Spiritual Identities: _____________________________________________________
Ethnic and Racial Identities:
____________________________________________________________________________
Please describe any other parts of your cultural identities you feel are important for
your therapist to know:
____________________________________________________________________________
____________________________________________________________________________
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Please describe your average monthly frequency and amount used of the following
substances:
Alcohol:______________________________________________________________________
Caffeine:_____________________________________________________________________
Tobacco:_____________________________________________________________________
Prescription drugs for which you do not have a prescription:
____________________________________________________________________________
Marijuana:____________________________________________________________________
Other non-prescription
drugs:_______________________________________________________________________
MEDICAL HISTORY
Please list any current medications you are prescribed:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please name any chronic conditions you have been diagnosed with:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please record any major hospitalizations for either medical or psychiatric reasons:
____________________________________________________________________________
____________________________________________________________________________
Have you participated in psychotherapy in the past? If so, what were your reasons for
attending?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Generally, how do you feel about beginning psychotherapy now?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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EMERGENCY CONTACT
If Emergency, Contact: ________________________________________________
Relationship: ________________________________________________________
Address: ____________________________________________________________
Home Phone: ________________Work Phone: ____________________________
Legal Next of Kin: ______________________ Relationship: _________________
Address: ___________________________________________________________
Home Phone: ________________Work Phone: ___________________________
I HAVE READ THE OFFICE POLICY AND ACCEPT ITS CONTENTS
_______________________________________ ____________________________
Signature
Date
_______________________________________ _____________________________
Additional Client or Parent Signature
Date
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