Janell W. Harvey, LPC  

 Islands Counseling   805 Holcomb Boulevard  

Ocean Springs, MS  39564 Appointment: 228 324-5767     Counselor: 228 326-2023

Islands Counseling Effective Date: 06/30/05

mbarksdale@islandscounseling.com               www.islandscounseling.com

CLIENT INFORMATION FORM

Name: _________________________________________  Social Security #____________________

Date of Birth:________________ Age: _______  Sex:________   Marital Status:________________

Address Physical (include city, state, zip):_______________________________________________

Address Mailing (include city, state, zip):_________________________________________________

Home # (     )____________________ Work # (     )______________________

Cell # (     )__________________________

Email address:_____________________________________________________

May I contact you by e-mail?_____________________________

Occupation:______________________ 

Years of Education/Degree:____________________________

Insurance Company:_______________________     Subscriber ID#:__________________________

Group #:________________  Policy # ___________________

Address of Insurance Company:_______________________________________________________

Name of Policy Holder:____________________________ Relationship to Client:________________

Address: (if same as insured put same)_________________________________________________

Social Security # of policy holder:_____________________  

Date of Birth of policy holder:_____________

Employer:_________________________________________________________________________

Emergency Contact:__________________   Relationship:______________   Phone:_________________

Referred By : (Choose one) Insurance company, person/organization, phone book,  other referral (list name)

____________________________________________________________________________________

May I thank the referral? Yes / No 

RELEASE/PAYMENT AUTHORIZATION: I agree to provide payment in full at the time of service to Islands 

Counseling. I authorize the release of medical information necessary to process an insurance claim on my behalf.  I   acknowledge that I received a copy of the HIPAA Privacy Notice.

Signed: __________________________________________          Date: ___________________