Personal Information Form



	Catherine Stone, MSW, LISW-CP
	210 West Stone Ave, Greenville, SC 29609
	864-238-2003

www.betterthinking-betterlife.com

Personal Information Form

Your personal information and signed consent to begin counseling is necessary, and it is important to have this information on file.

Today's Date ______________

Name _______________________________________

Age _______________ Birthdate __________________

Address _______ ________________________________________________________

City____________________________ State, Zip __________________________

Email___ _________________________________________________

Home Phone_______________________ Work Phone__________________________

Cell Phone________________________________

Occupation/ Employer____________________________________________________

Marital status__________________ Name of spouse/partner______________________

How long have you been together? ______________________

Please list names and ages of any children:

Name of closest friend/relative _________________________Phone _______________

What do you wish to achieve during your time in counseling?

Prior medical and psychological records may be requested as part of the counseling process. Please make sure that all information given below is correct.

Name of Insurance Company ____________________________________________

Whose name is on the insurance card? ____________________________________________

The insured’s date of birth: _________________ The insured’s social security number: __________________

Who is your regular physician? __________________________________________________________________

What is the name of the practice and phone number? _____________________________________________

Are you seeing any other physicians? If so, please list:

Are you taking any medication? If yes, please list:

Have you ever been hospitalized for a physical illness?____ When and why?

Have you ever been in a psychiatric hospital? When and why?

Any previous therapy/counseling? If yes, name of therapist(s):

When and number of sessions:

Reason:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Catherine A. Stone, MSW, LISW-CP. I understand that I am financially responsible for any balance. I also authorize Catherine A. Stone, MSW, LISW-CP or insurance company to release any information required to process my claims.
Patient/Guardian signature		Date