OKLAHOMA CHRISTIAN COUNSELING CENTER
Oklahoma Christian Counseling Center
Confidential Application
Date ____________________ Referred by __________________________
Name _______________________________________ Birthdate ______________ Age _____ Gender _____
Address __________________________________________________________________________________
Street City State Zip
Phone ________________________ ________________________ ________________________
Home Office Cell
Email _____________________
Occupation _____________________________________ Employer _________________________________
Social Security Number __________________________ Education/Degree ____________________________
Emergency Contact Person _____________________________ Phone Number _________________________
Health Insurance Information
Primary Insurance Co. __________________________ Secondary Insurance Co. _____________________
I.D. No. _____________________________________ I.D. No. __________________________________
Group No. ___________________________________ Group No. ________________________________
If you are not the Insured, please also provide the following information:
Insured’s Name _______________________________ Insured’s Name ____________________________
Insured’s Birthdate ____________________________ Insured’s Birthdate __________________________
Insured’s SS# ________________________________ Insured’s SS# ______________________________
I am the insured or authorized person, I authorize the release of any medical or other information necessary to process this claim, and I authorize payment of medical benefits to the provider.
__________________________________ _______________________
Signature Date
Reminder Calls
Our center will accommodate you by calling to remind you of your appointments if you so desire. The message may be left on your voice mail or with whoever may answer your phone. The message will be: “This is (receptionist) at (your therapist’s) office reminding you of your appointment (tomorrow) at (time).” Please indicate below whether or not you desire a reminder call by initialing the option that you choose. Also, please understand that you are responsible to keep your appointments whether you receive a call or not.
_____ Yes, I want you to call to remind me of appointments and I authorize you to leave a message at the
following number(s): ____________________ _______________________ _____________________
_____ No, I do not want you to call to remind me of appointments.
PLEASE PROVIDE THE FOLLOWING IMPORTANT INFORMATION
Current Marital Status: ___Single ___Widowed ___Divorced ___Separated ___Married
How many times have you been married? _____ Divorced? _____ Widowed? _____
Spouse’s Name _________________________________ Occupation: ________________________________
Name(s) of Children Age School Grade Lives with you?
________________________________ ______ ___________ ____________
________________________________ ______ ___________ ____________
________________________________ ______ ___________ ____________
________________________________ ______ ___________ ____________
Name, age and relationship of anyone else living in your home: ______________________________________
Primary Care Physician ____________________________ Psychiatrist _______________________________
Are you willing to sign a release for your therapist to speak with your physician? ______ Psychiatrist? _______
Significant illnesses and hospitalizations _________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Current medications _________________________________________________________________________
__________________________________________________________________________________________
Please list any history of previous mental health treatment:
Provider Dates How many sessions this year?
_____________________________________________ __________________ _______________________
_____________________________________________ __________________ _______________________
_____________________________________________ __________________ _______________________
Religious affiliation: _____________________________________ Pastor’s name: ______________________
Reason for today’s visit (circle all that apply):
Anxiety Parenting Social Relationships Alcohol/Drugs Depression
Stress Management Family Divorce Adjustment Court Related Work Related
Religious/Spiritual Marital
Additional information to help us better understand your needs:_______________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Please indicate if any of the following symptoms apply to you and for how long:
How long? How long?
___ Difficulty sleeping______________ ___ Change in eating habits ______________
___ Guilt feelings ______________ ___ Difficulty functioning ______________
___ Suicidal thoughts ______________ ___ Homicidal thoughts ______________
___ Social isolation ______________ ___ Inability to sit still ______________
___ Racing thoughts ______________ ___ Unreasonable fears ______________
___ Anger ______________ ___ Physical violence ______________
___ Sexual conflicts ______________ ___ Memory difficulties ______________
___ Seeing visions ______________ ___ Hearing voices ______________
___ Heavy medication use __________ ___ Head or stomach aches ______________
___ Sad/Discouraged ______________ ___ Heavy alcohol use ______________
___ In legal trouble ______________ ___ Religious conflicts ______________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICES AND AGREEMENTS
My signature on this document indicates that I have read, or had read to me, and fully understand the following notices and agreements of the Oklahoma Christian Counseling Center.
* PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT
* OKLAHOM NOTICE FORM
(Notice of Psychologists’ Policies and Practices to Protect the
Privacy of Your Health Information)
* ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
My signature also verifies that I have received copies of these documents and agree to the terms therein.
___________________________________ ________________________
Signature of Client or Legal Representative Date
Description of representative’s authority to act for the client:
__________________________________________________________________________________________
___________________________________ ________________________
Signature of Witness Date
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