Gallien Counseling
Angela Ros
s Gallien, MA, LPC, NCC
Licensed Professional Counselor
(205)
365-7699
Offices in Hoover, Homewood and Dora
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Gallien Counseling Offices in Hoover, Homewood and Dora
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Gallien Counseling GENERAL INFORMATION: Date _____-_____-_____Name __________________________________ Date of Birth_____-_____-_____ Address ________________________________________________________________ City ____________________________________ State _____ Zip ______________ Home phone ____________ Work phone ____________ Mobile/Other ____________ E-mail Address ___________________________________________________________
Person to notify in the event of an emergency _____________________________________ Emergency contact relationship to you __________________________________________ Contact’s phone number ____________________________________________________ Referred by ______________________________________________________________
EDUCATION: Highest grade/degree completed __________ Where ______________________________ Current Occupation/Current Employer __________________________________________
FAMILY: Present Relationship Status: __ Married or in a primary relationship OTHERS LIVING IN HOUSEHOLD:
General physical health is ( ) Excellent ( ) Good ( ) Fair ( ) Poor Are you presently taking medication(s)? _________ If yes,
please list ___________________ Please list and describe any physical problems you
presently have ______________________ Psychiatrist’s
name__________________________________________________________ BRIEF DESCRIPTION OF PROBLEM: State your concerns, why you are seeking counseling and when the difficulties began (suddenly, gradually).________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please describe your area(s) of strength: _________________________________________ ________________________________________________________________________ ________________________________________________________________________ NOTE: In order to prevent misunderstanding about insurance please note that:
(1) All services
furnished are charged directly to client. Thank you.
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Gallien Counseling
Cell: 365-7699
Name __________________________________ Date of Birth_____-_____-_____
Address ________________________________________________________________
City ____________________________________ State _____ Zip ______________
Home phone ____________ Work phone ____________ Mobile/Other ____________
E-mail Address ___________________________________________________________
Person to notify in the event of an emergency _____________________________________
Emergency contact relationship to you __________________________________________
Contact’s phone number ____________________________________________________
Referred by ______________________________________________________________
EDUCATION:
Highest grade/degree completed __________ Where ______________________________
Current Occupation/Current Employer __________________________________________
FAMILY:
Present Relationship Status:
__ Married or in a primary relationship
__ Single: How long? _____________
__ Divorced: How long? __________
__ Dating
__ Widowed
__ In a new relationship (6 months or less)
__ Other
OTHERS LIVING IN HOUSEHOLD:
Name
Relationship Age
Comments
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MEDICAL INFORMATION:
General physical health is ( ) Excellent ( ) Good ( ) Fair ( ) Poor
Are you presently taking medication(s)? _________ If yes,
please list ___________________
________________________________________________________________________
Please list and describe any physical problems you
presently have ______________________
________________________________________________________________________
Psychiatrist’s
name__________________________________________________________
BRIEF DESCRIPTION OF PROBLEM: State your concerns, why you are seeking counseling and when the difficulties began (suddenly, gradually).________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please describe your area(s) of strength: _________________________________________
________________________________________________________________________
________________________________________________________________________
NOTE: In order to prevent misunderstanding about insurance please note that:
(1) All services
furnished are charged directly to client.
(2) Information
will be provided to submit your own claims.
(3) Clients are
personally responsible for payment at time of service.
Thank you.