Alison Hoehn, MS, LPC, MAC, NCC
1240 Clairmont Road #202
Decatur, Georgia 30030
Phone 404-358-1076


CLIENT INTAKE FORM
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Client's full name

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Address

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Phone number        (home and cell, if applicable)

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Social Security number

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Age

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Date of birth

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Gender

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Marital status

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Referral from?

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Please briefly describe your previous treatment

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Your current medications, if any

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Please list your current household members

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Please briefly describe your reason for your psychotherapeutic interview

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Employer

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Work phone

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Employer's address

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Spouse/guardian name

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Spouse/guardian date of birth

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Spouse/guardian Social Security No.

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Spouse/Guardian employer

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Primary care doctor

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Phone number of primary care doctor

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Primary insurance company

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Phone number of your primary insurance company

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Address to mail claims

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Insured

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Insured ID number

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Insured Group number