New Patient Info | Child and Family Therapy

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CHILD AND FAMILY THERAPY CENTER OF MACOMB

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New Patient Info

Patient's First Name

Patient's Last Name

Patient's Birthdate

Patient's Insurance

Patient's Street Address

City

State

Zip Code

Primary Insured ID

Group Number

Relationship to Patient

Primary Insured Name

Primary Insured Birthdate

Therapist requested (optional)

Primary Contact Name

Primary Contact's Phone Number

Primary Contact Email (Client's email if 18 or older)

Referral Source

In-person or virtual

In-person

Virtual

Combination of Both

Type of therapy you are seeking

Individual Talk Therapy

Child Therapy

Couples Counseling

Family (Parents & Children)

Have you been referred for therapy by the court?

Therapy for child?

IF CHILD THERAPY, Please answer the following: What type of therapy services are you seeking for your child? Please check all that apply.

Behaviors

Trauma

Eating Concerns

ADHD

School Performance

Aggression

Self Harm

Following Directions

Relationships with Others

Autism

Anxiety

Depression

Gender Identity

Developmentally Delay (DD Diagnosis)

Harm to Others

Sexual Trauma

Sexual Harm to Others

IF CHILD THERAPY, has there been / is there CPS Involvement?

Office location preferred:

Days/times you prefer (please be as specific as possible):

Any other information that would be helpful to making the right match:

CHILD AND FAMILY THERAPY CENTER OF MACOMB

appointment@therapycenterofmacomb.com

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