Adult Information Form

INFORMATION FORM

Reason seeking treatment at this time:

Janneta Bohlander & Associates, LLC Information Form Purpose: We are usually quite successful in helping people cope with stress and difficulties, although no one can solve your problems for you. Your therapist will listen and be helpful to the fullest extent of his/her professional capabilities. It is by discussing your thoughts and feelings that we can work as a team to obtain the best results. All therapy sessions are completely confidential. No information will be released without your consent. Please print legibly.

TODAY’S DATE:

CLIENT NAME:

BIRTHDATE:

PHONE#

ADDRESS:

Address Line 1

City

State

Zip Code

COUNTY OF RESIDENCE:

CELL PHONE:

SEX:

MALE
FEMALE
TRANS
OTHER

EMAIL:

HOME PHONE:

WORK PHONE:

IS IT OK TO LEAVE A MESSAGE AT HOME PHONE?

OTHER RESPONSIBLE PERSON (if not the client):

NAME:

RELATIONSHIP TO CLIENT:

PHONE#

Address

Address Line 1

City

State

Zip Code

COUNTY OF RESIDENCE:

CELL PHONE:

EMAIL: *

HOME PHONE:

WORK PHONE:

IS IT OK TO LEAVE A MESSAGE AT HOME PHONE?

IS IT OK TO LEAVE A MESSAGE ON YOUR CELL PHONE?

EMPLOYER:

IN CASE OF EMERGENCY CONTACT:

NAME: *

PHONE:

RELATIONSHIP:

CLIENT’S CURRENT MEDICATIONS:

ANY ALLERGIES?

PHYSICIAN:

PHONE #

PERMISSION TO CONTACT PHYSICIAN?

HAS THE CLIENT EVER HAD THERAPY?

WHEN?

BY WHOM?

WAS IT HELPFUL?

Financial Agreement

Self-Pay: I will be paying for the services I receive at Janneta Bohlander & Associates, LLC.

I will make a full payment of (fill amount below):

Each time I come unless other approved arrangements have been made.

NOTE: We do not bill insurance companies directly, and payment is expected at the time of service. A receipt will be given to you to submit to your insurance company. All therapy appointments are scheduled in advance. We reserve a specific time period to each client. It is important that you realize that a block of time has been set aside for you. We require 24 hours prior to your scheduled appointment to cancel. If not received within 24 hours you will be charged for the session.

Client signature (Parent if Minor):

Date:

Therapist:

Witness:

INFORMED CONSENT By my signature, I am indicating I have read and understood the Informed Consent Notice and the notice of Privacy Practices. I am requesting professional services from Janneta Bohlander & Associates, LLC. I understand that I can discuss any questions or concerns I have regarding my treatment or these policies with my therapist. I also understand I may withdraw this consent and terminate therapy at any time for any reason, but it must be in writing and signed by myself or my legal guardian.

Client signature (Parent if Minor):

Date:

Therapist signature

Date:

Janneta Bohlander & Associates, LLC

Janneta Bohlander, LMFT

83 East Avenue, Suite 208

203-521-0805

Janneta Bohlander, LMFT

CT license number 000955

Tax ID 20-3204106

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