8771 Wolff Ct., Suite 210
Westminster, CO 80031
Telephone: (303)257-7623
Fax: (303)427-2378

                                                                                              CLIENT INFORMATION


Name:________________________________ Today’s date:____________

Address:______________________________________________________
                                     (Street City Zip)

Telephone Numbers H:___________________ W:____________________

Cell:__________________                Date of birth:___________

Marital Status (Please circle one): single, married, separated, divorced, widowed

Employer:_______________________ Occupation:___________________

Employer’s Address:____________________________________________

Name of spouse:__________________ Occupation:___________________

Spouse’s employer:________________ Spouse’s work phone:___________

Spouse’s cell phone:_______________ Spouse’s date of birth:___________

(needed only if spouse will be in therapy)

Family members:

Name                         Age         Relation                            Live with you?

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Referred by:_______________________ Physician:___________________

Previous psychotherapy? Yes/No If Yes, therapist’s name:________________

State in your own words the nature of your chief complaint:______________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

(forms/client.doc)
Client Information Form

for patients of Tom Olschner, Ph.D.
Home