CLIENTS

Client Forms & Releases

Release of info

New client form

New client form - Couples

Release of Information

I, , give permission for Mickie Simon to release information to and for to release information to Mickie Simon.

Thank you

Release of Info

New Client Form

Medical History (Please indicate any serious medical illnesses and current physician. Also, please note date of last physical exam and current medications):

Prior Therapy Experience: (Please note any prior therapy you have had and include the name of the therapist and the estimated dates of treatment)

Reason for Seeking Therapy at this time:

Referred by:

Thank you

New Client Forms for Couples

New Client Form for Couples

Part 1 Your Information

Medical History (Please indicate any serious medical illnesses and current physician. Also, please note date of last physical exam and current medications):

Prior Therapy Experience: (Please note any prior therapy you have had and include the name of the therapist and the estimated dates of treatment)

Reason for Seeking Therapy at this time:

Referred by:

Thank you

Part 2 Partner Information

Medical History (Please indicate any serious medical illnesses and current physician. Also, please note date of last physical exam and current medications):

Prior Therapy Experience: (Please note any prior therapy you have had and include the name of the therapist and the estimated dates of treatment)

Reason for Seeking Therapy at this time:

Referred by:

Thank you