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CRT COUNSELING-Change, Renewal, Transition, PA
CLINICAL INFORMATION SHEET

NAME:_______________________________________	PHONE (H)_______________________	MESSAGES O.K.?______
ADDRESS:___________________________________ ____________________________________________	(W)_________________________________	MESSAGES O.K.?______
	(C)__________________________________	MESS AGES O.K.?_____
	CITY________________________________	ZIP___________________
DOB:_______________   SS#:____________________	INSURANCE:_________________________

SUBSCRIBER'S NAME: _______________________  SS#____________________________

HOUSEHOLD MEMBERS

NAME:____________________________________________________________	AGE________	RELATIONSHIP__________
NAME:_____________________________________________________________________	AGE________	RELATIONSHIP__________
NAME:____________________________________________________________	AGE________	RELATIONSHIP__________
NAME:____________________________________________________________	AGE________	RELATIONSHIP__________
EMPLOYER:_______________________________________________________

LENGTH OF EMPLOYMENT:_________________  POSITION/TITLE:_______________________________________

ARE YOU CURRENTLY UNDER A PHYSICIAN'S CARE?______REASON:__________________
NAME OF PHYSICIAN:______________________  PHONE #:____________________________

CURRENT MEDICATIONS:  _________________      PRESCRIBED FOR:____________________
................................................... _________________...................................... ____________________
...................................................._________________......................................____________________
....................................................._________________ .................................... ____________________

HAVE YOU EVER SOUGHT TREATMENT FOR SUBSTANCE ABUSE OR PERSONAL ISSUES BEFORE?____IF SO, PLEASE EXPLAIN:_______________________________

DO YOU CURRENTLY HAVE ANY LEGAL ACTION PENDING?____IF SO, PLEASE EXPLAIN:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

ARE YOU ON PROBATION/PAROLE?____IF SO, PLEASE EXPLAIN____________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
WHAT CHANGES DO YOU EXPECT FROM COUNSELING?_______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

IN CASE OF EMERGENCY PLEASE CONTACT:   _____________________PHONE #:___________

YOU ARE FINANCIALL Y RESPONSIBLE FOR ALL SCHEDULED APPOINTMENTS UNLESS A 24 HOUR CANCELLATION NOTICE IS GIVEN