Last Name:
First Name:
Middle Name:
Email:
Telephone:
Fax:
Street address/PO Box:
City:
State:
Zip:
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AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IA
IL
IN
KS
KY
LA
MA
MD
ME
MI
MO
MN
MS
MT
NC
ND
NE
NH
NJ
NM
NY
NV
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
What is the best time to reach you?
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Morning
Afternoon
Evening
I request
coaching
or counseling
(mark one) service from Mathis & Associates .
Preferred date & time for appointment:
Date:
Time:
What type of coaching or counseling are you requesting?
Client Signature
PART II: Client Intake (to be completed by all Clients)
Race:
Gender:
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Asian Black or African American
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
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Male
Female
Do you consider yourself a person with a disability?
What inspired you to contact us?
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Web page
Friend
Referral from agency
Referral from therapist
Attended training/workshop/seminars and decided I needed more counseling
Television/Radio Newspaper
Word of Mouth
Other
Are you currently using any medications?
If yes, what medication(s):
Doctors contact information who prescribed the medicines:
How long have you been using these medication (s):
Number of children and their ages:
Are you married, single or divorced?
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Married
Single
Divorced
Any history of family mental illness?
If yes, please describe:
Have you ever tried to commit suicide or have
If yes, when and what happened?
Have you ever been convicted of a felony or crime?
If yes please describe:
Describe specific assistance requested in the space provided.
By checking this box , you understand that all services are confidential and information will not be released without written consent between you and Mathis & Associates and/or their representative. Should you have a legal case and any counselor or coach at Mathis & Associates is subpoenaed to testify, there will be extra charges for appearing in court.
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Dr. Mathis & Associateskathie@drkathiemathis.com
If you need lodging while attending a seminar or training, please contact us for further information.
