Please print page and mail the filled out form to the above address.

DATE OF INITIAL VISIT:____________________________
CLIENTS NAME______________________________________
ADDRESS (STREET)__________________________________
CITY, STATE, ZIP CODE:_____________________________________________
TELEPHONE # (HOME) ____________________ (WORK)_________________
MARITAL STATUS: ______________
Date of Birth: ______________
SS#_______________

EDUCATIONAL BACKGROUND:_______________________________

PLACE OF EMPLOYMENT:__________________________________

OCCUPATION:___________________________________________

PERSON RESPONSIBLE FOR PAYMENT

NAME:_________________________________________________
ADDRESS:______________________________________________
DATE OF BIRTH OF SUBSCRIBER:___________________________
RELATIONSHIP TO CLIENT:_______________________________
SS#:______________ AUTHORIZATION #:__________________________

INSURANCE CARRIER:_______________________
_________________________________________

REFERRED BY:_____________________________

BRIEF DESCRIPTION OF CURRENT PROBLEM(S):_____________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

HAVE YOU HAD PREVIOUS TREATMENT FOR EMOTIONAL DIFFICULITY?__YES __NO

IF SO, WHEN?____________ PROBLEM:_________________________

TREATED BY:_______________________________

ARE YOU CURRENTLY ON MEDICATIONS? __YES __NO
PLEASE LIST MEDICATIONS:__________________________________
__________________________________________________________

A COPY OF YOUR INSURANCE CARD WOULD BE APPRECIATED

I authorize the release of any information necessary to process insurance claims. I request that payments of benefits be made directly to Michelle M. Domowicz, M.A. I understand that managed care companies require my service provider to review my treatment verbally and/or in writing to obtain authorization for service. I realize that occasionally managed care companies may require an on-site review of my chart. I agree to pay all co-payments and deductibles at the time service is performed and that I am responsible for payment of services provided that are not covered by my insurance plan.

Signature of Responsible Party:____________________________________

Date:________________