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

ctrforfamilies@

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 ___________________

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