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Minor Client Demographic Form

Minor Client Demographic Form (Under 17)

Step 1 of 5

20%

Patient Information
Name*
First Last
MI
Nickname
Date of Birth*
Social Security Number
Gender*
Guardianship Status
- Biological Parent
- Non-Parent Relative
- DCS Custody
- Other
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Father's Name
First Last
Father's Date of Birth
Father's Social Security Number
Mother's Name
First Last
Mother's Date of Birth
Mother's Social Security Number
Primary Contact's Email Address
Patient's Employment Status
- Employed - Full Time
- Employed - Part Time
- Student - Full Time
- Student - Part Time
School
County
Current Grade
Will you be using insurance?*
- Yes
- No

Physician Referral Information
Primary Care Physician
Physician Phone Number

Responsible Party and Insurance Information
Policy Holder's Name
First Last
Relationship to Patient
Policy Holder's Date of Birth
Policy Holder's Social Security Number
Policy Holder's Home Number
Policy Holder's Work Number
Policy Holder's Home Address
Street Address Address Line 2 City State ZIP Code
Policy Holder's Employer
Employer's Phone Number
Insurance Carrier
Policy Number
Group Number

Emergency Contact Information
Name
First Last
Relationship to Patient
Home Phone Number
Cell Phone Number
Work Phone Number

Methods of Communication
Do we have permission to...
Untick if you do not wish to be contacted by this method.
- Contact you at work?
- Contact you at home?
- Send mail to your home?
- Leave a message on your answering machine?
- Send you email?
Where did you hear about Righteous Oaks?

'They will be called oaks of righteousness, a planting of the Lord for the display of his splendour.’

~Isaiah 61:3

© 2012 - Righteous Oaks Counseling