New Client

To better understand your needs, please fill out this form as completely as possible.

Name Birth Date
Address City
    ZIP
Home Phone Work
    Cell
Employed? Yes No If yes, Where?
Marital status:    
Spouse/ significant other in the household? Yes No Name:
Employed? Yes No If yes, Where?

Please list children present in the household

Name Age Name Age Name Age
1. 3. 5.
2. 4. 6.

If Client is Child Under Age 18

Mother:
 lives with child?
Yes No		 Father:
 lives with child?
Yes No
If no,address If no,address
Place of Employment: Place of Employment:
       
School Grade

 

Please check all of the PERSONAL STRENGTHS you feel you or your child possess.

ADULTS
Other:
CHILDREN/ADOLESCENTS
Other:

Please check all of the STRESS FACTORS  that you believe apply to you or your family’s situation.

Shyness   Parenting    Finances   Stress
With Parents Suicide Assertiveness Death
Communication   Sleeping Separation Guilt
Blended Family    Sexuality  Relaxation    Anger
Relationship Physical Abuse  School  Depression
Divorce Verbal Abuse    Job Related   Legal
Marriage Preparation    Sexual Abuse    Homosexuality  Panic
Alcohol/Drugs  Nervousness/Anxiety    Medical Dating
Marital  Infidelity   Weight  Extended Family

Other

INSURANCE INFORMATION
You may be asked to call your insurance company to ensure treatment and provider are covered

Name of Insurance:   Member’s Name:

Do you have Medicaid?

Relationship to Client:    Self      Father      Mother      Step parent

Member’s Place of Employment: ID Number:  

If self-pay, will you need a payment plan? 

No, I will pay for each session      Yes, I will pay $ per month.

Kim Arter photo
Kim R. Arter
LMHP, CPC

Arter Counseling
Services
11414 W. Center Rd.
Suite 239
Omaha, NE 68144
(402) 330-1633
(402) 333-0417 fax
email