CLIENT  SCHOOL  INFORMATION
SCHOOL ADDRESS
SCHOOL NAME
Client Information Form 
INSTRUCTIONS:

Length: About 10 minutes

DO NOT LEAVE THE PAGE. YOU CANNOT SAVE AND COME BACK LATER. COMPLETE ALL THE BOXES. WHEN FINISHED, CLICK THE BUTTON [SUBMIT] TO SEND YOUR INFORMATION CONFIDENTIALLY TO WICKS PSYCHOLOGICAL SERVICES. 

ALL INFORMATION IS REQUIRED - IF AN ITEM DOES NOT APPLY, KEY IN N/A.

TODAY IS:
CLIENT INFORMATION

Child/Adolescent under 19 years of age

CLIENT PROPER NAME

*

GENDER
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BIRTH DATE (MM/DD/YYYY)
ADDRESS
HOME PHONE  NUMBER
CELL PHONE  NUMBER
E-MAIL ADDRESS

*

REQUIRED: Please enter your first and last name to complete the form. Please complete all fields. Enter "na" if not applicable.

EMPLOYMENT STATUS
GRADE
EMPLOYER NAME
EMPLOYER ADDRESS
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CLIENT  EMPLOYMENT  INFORMATION
IF YOU SELECTED "SCHOOL,"
THEN ENTER A GRADE HERE.
CONSENT FOR TREATMENT
PROCEED TO GIVE CONSENT:

All information sent is held as strictly confidential. 

1). CHECKBOX Click this box to indicate: "Yes I give consent"

2).  SIGNATURE BOX  "My full legal name will act as my signature."

3). SUBMIT BUTTON

4). RESULT MESSAGE

If for any reason an appointment cannot be kept, please notify the Wicks Psychological Services Office at least 24 hours in advance. Unless the cancellation is due to an emergency, there will be a charge for the time that was reserved for you. This is at the discretion of your doctor.

INSTRUCTIONS

1). Click on the [CHECKBOX] to display a check mark.

2). Click on the [SIGNATURE BOX] to type in your full legal name.

3). Click on the [SUBMIT] button once to send this form.

 

4). The [RESULT MESSAGE]. If the submission was good, then the        Result Message will display as. . .

     "This form has been submitted successfully."

      If there is any error on the page, the Result Message
      will display as. . .

     
"OOPS! There is an error somewhere. Fix those and
        come back to  submit again."

The appearance of red boxes means the information is required, but the box is empty. If the item does not apply, type in "na."

EMERGENCY CONTACT
EMERGENCY CONTACT NAME
EMERGENCY CONTACT ADDRESS
EMERGENCY CONTACT PHONE NUMBER
PARENT/GUARDIAN INFORMATION
PROPER NAME OF PARENT/GUARDIAN
ADDRESS
 PARENT'S PHONE  NUMBER
E-MAIL ADDRESS
PARENT/GUARDIAN'S
BIRTH DATE
(MM/DD/YYYY)
PARENT'S CELL PHONE  NUMBER
PARENT/GUARDIAN   EMPLOYMENT  INFORMATION
EMPLOYER NAME
EMPLOYER ADDRESS
PARENT'S WORK PHONE NUMBER
RELATIONSHIP TO THE CLIENT
CASEWORKER   INFORMATION
CASEWORKER NAME
CASEWORKER E-MAIL
CASEWORKER PHONE NUMBER
COPYRIGHT © 2019 WICKS PSYCHOLOGICAL SERVICES, INC. ALL RIGHTS RESERVED.