MM slash DD slash YYYY
(please note whether living in or outside of the home)
FINANCIALLY RESPONSIBLE PARTY
An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
(Current & past medications & dosages, illnesses, etc.)
(Client or Partner)
(Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)
(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
- Other care professionals you are currently undergoing treatment with including a therapist doing individual counseling or others (e.g. acupuncturist, chiropractor, medical specialists, etc.)
This field is for validation purposes and should be left unchanged.