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New Client Questionnaire
Name
(Required)
First
Last
Is the Client a Minor?
(Required)
Yes
No
Minor Information
Parent/Guardian Name
(Required)
First
Last
Relation to Client
(Required)
Does the Parent/Guardian have full custody of the client?
(Required)
Yes
No
If no, is there a custody agreement?
(Required)
Yes
No
Is there any DHS involvement with the Client?
(Required)
Yes
No
Client Information
Date of Birth
(Required)
MM slash DD slash YYYY
Location Preference
(Required)
Eugene/Springfield
Junction City
Phone
(Required)
Email
(Required)
Primary Insurance
(Required)
Secondary Insurance
Clinician Preference
Schedule preference or limitations
Do you have any previous diagnoses?
(Required)
What are you hoping to work on in therapy?
(Required)
Have you (or the Client) made a suicidal threat or attempt in the last 2 years, or do you (they) have plans to harm yourself (themselves)?
(Required)
Yes
No
Please provide additional details about any suicidal threats during the last 2 years
(Required)
Notifications
