North Georgia Family Counseling Centers, Inc. (678) 242-9355 [email protected] 5100 S. Old Peachtree Rd. Norcross, GA 30092 www.ngfcc.org Client Information Sheet Name: _______________________________________________________________ DOB: ______________________ Last First MI Name you prefer to be called: ____________________________________________________ Address: _____________________________________________________________________ Street City State Zip Gender: ________________ Marital Status: ________________________________________ Phone: __________________ _______________________ ________________________ Home Work Note: Please only provide numbers that can be used to contact you. E-Mail: ___________________________________ Work Status: FULL TIME Cell BILLING SCHEDULING CLIENT COMMUNICATION Please circle (above) how e-mail can be used PART TIME STUDENT OTHER IF STUDENT: NAME OF SCHOOL ____________________________________________________ Employer: _______________________________ Occupation: _________________________ Emergency Contact: _____________________________________ Phone: ________________ Last First Emergency Contact Relationship to You: ______________________________________ Responsible Party Information: (if other than self): Name: ___________________________________ Relationship: ________________________ Address: _____________________________________________________________________ DOB: __________________ Gender: M or F Employer: _____________________________ How did you find out about our practice? _____________________________________________________ For therapist use only Location: _____________________________ Service: _______________ Per unit charge: ______ Therapist: __________________Status: _______________ Diagnosis Code: ___________ Consent? Symptom Checklist? Release of Information?
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