The Center for Families, LLC

The Center 4 Families, LLC

27 Gamecock Ave. Suite #202 Charleston, SC 29407 Helen Elliott Wheeler, M.Ed. LPC (843) 763-5837; Fax (803)753-0134 [email protected] Client Information for Counseling

Client’s Name______Date______

Address______City, State, Zip______

Daytime phone______Cell ______email ______

Date of Birth ___/___/_____Who referred you?______May we thank that person? Y N

Emergency Contact Information: Name______Phone ______

Address______Relationship______

If the client is under 21: Parent/Guardian printed name ______Phone ______

School ______grade______

Medications______

Physician’s name ______Phone______Do I have permission to contact? Y N

Have you ever been told or thought that you had a problem with substances (drugs-legal or illegal) or alcohol?

Y N If yes, what substance(s)?______

Are sleeping problems or eating problems? (Circle one or both) Too much ?___Too little___

Estimate how much time you spend online per week: FACEBOOK _____YOUTUBE ______GAMING

______BROWSING _____TEXTING ______OTHER ______WORK______SCHOOL ______Do you feel your technology use is balanced?_____ How could it be improved?______

If there is a secondary insurance company, please provide information on the back of this sheet Signature (by signing here, you are granting permission to receive counseling treatment for yourself or your child or other dependent, and when appropriate, to file for insurance payment) Payment of any applicable deductibles, co-pays, etc. are expected at the time of services. We accept Visa and MasterCcard:debit or credit Please sign here Client or Guardian ______

For office use only Insurance co .______Authorization ______# of visits ______Date______of auth Co-pay amt______deductible am’t ______