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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