New Client Registration Name * First Name Last Name Date of Birth MM DD YYYY Age Sex/Gender Identity Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Can I call this number? * Yes No May I leave a message? * Yes No Person Responsible for the bill? * Relationship * Employer Information Employer Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Work Phone (###) ### #### Can I call this number? Yes No May I leave a message? Yes No Medical and Referral Information Name of Physician Date of last physical MM DD YYYY Who referred you to my office? Relationship Household Information Adults living with you Please provide the name, sex/gender identity, age, and relationship to you for each adult living with you. Children living with you Please provide the name, sex/gender identity, age, and relationship to you for each child living with you. Emergency Contact In Emergency Contact * First Name Last Name Relationship to Contact * Address of Contact * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone of Contact * (###) ### #### Can I call this number? * Yes No May I leave a message? * Yes No Work/Home/Alternate phone of Contact (###) ### #### Can I call this number? Yes No May I leave a message? Yes No Current Distress Level Please rate your level of distress on a scale of 1 – 10 * 1, No Distress 2 3 4 5 6 7 8 9 10, Severe Distress Thank you!