Celebration Counseling

Client Information

Personal Information: __________________________________________________

Name: _____________________________________________________________

Drivers License #: _____________________________________________________

Home Address: _______________________________________________________

City/State/Zip: ________________________________________________________

Home Phone: ________________________________________________________

Date of Birth: _________________________________________________________

Phone you would like to receive calls: ______________________________________

Social Security Number: ________________________________________________

Marital Status: ________________________________________________________

Occupation: __________________________________________________________

Employer: ___________________________________________________________

Name of Spouse/Partner: _______________________________________________

Name of Children and ages: _____________________________________________

If Client is a Minor:

Parent or Guardian Address: ____________________________________________

City/State/Zip: ________________________________________________________

Person Responsible for Account: _________________________________________

The undersigned accepts responsibility for the cost of all services rendered to the patient and attests that the information given is true and correct. The undersigned further understands that APPOINTMENTS MUST BE CANCELLED ONE FULL BUSINESS DAY PRIOR TO THE SCHEDULED TIME OR THE LATE FEE OF $60.00 WILL BE CHARGED.

Signature: _____________________________________

Date: _________________________________________