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625 Main St. #23
Windermere, FL 34786
407-405-5514


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 Client Assessment Questionnaire

  You must completely fill out the form below so we can better service your needs.






of Birth
Male      Female


Street
City


State

Zip

Insurance Information
Full Name of Insured
Social Security # of Insured
Insured's Date of Birth

(if different)

Street 1
Street 2

City

State

Zip

Name of Insurance carrier for Mental/Behavioral
Health Benefits
Complete Address for Mental/Behavioral Health claims
Phone Number for Mental/Behavioral Health claims
Insurance ID number
Co-pay amount (if known)
Deductible amount (if known)
   
   
Immediate Family Members


Yes      No




Medical History
Yes      No

Phone number:
Yes      No (If "No," please state reason for refusal

I have reviewed the Practice's Notice and Privacy Practices and understand that my protected health information may be used by the Practice as described in the notice.

Yes      No

Food or drug allergies?

If yes, nature of reaction:

Yes      No

Family History: (psychiatric history, substance abuse history, suicide and homicide of family members, history of abuse)

Psychosocial History: (social/cultural/spiritual factors and support, education and job history, legal history, sexual orientation, utilization of community resources, significant childhood events)

Children/Adolescents: include developmental history and educational history:

Marriage/Family: (marital history, including current/prior marriages/significant relationships; names/relationships with children


Interests & Activities

Strengths & Weaknesses: