Client Assessment Form | Augustine Counseling, LLC

Date:

Name:

Address:

Phone Number:

DOB:

SS#:

Occupation:

Insurance Company:

Insurance ID #:

Insurance Group #:

Policy Holder:

Co-Pay/Deductible Amount:

Referred By:

Please Describe Reason You Are Seeking Therapy:

Current or History of Mental Health Issues (Personal and Family):

Please List Any Current or History of Prescribed Medicines:

Please List Any History of Behavioral Health Treatment (i.e. Outpatient Therapy, etc.):

In Your Own Words, Please Describe Your Areas of Strength/Interests:

Email Address*

Augustine Counseling, LLC
Client Assessment