Demographic Information "*" indicates required fields Name* First Middle Last Client NumberToday’s Date MM slash DD slash YYYY Home Address Street Address City State / Province / Region ZIP / Postal Code Mailing Address (if different from home address) Street Address City State / Province / Region ZIP / Postal Code County of Legal Residence Out of State Unknown Social Security NoHome PhoneWork PhoneCell/Other PhoneWhere may we contact you? Home Address Mailing Address Home Phone Work Phone Where may we leave a message? Home Work Other Client AgeDate of Birth MM slash DD slash YYYY Gender Male Female Marital Status Married Single Divorced Widow Separated Race White Black/African American Native American Asian Unknown Native Hawaiian/Other Pacific Islander Alaskan Native Multiple Race Are you a US citizen? Yes No Ethnicity Puerto Rican Mexican Cuban Other Hispanic Not Hispanic / Latin Parent/Guardian/Custodian if Minor (include name and address)Parent/Guardian/Custodian Phone Home Cell Emergency Contact (name and address)RelationshipEmergency Contact Phone Home Cell Primary Care Medical Provider (name and address)PhoneEmployer (name and address)How long employed?Contact PhoneSchool NameEducational levelContact PhoneDoes client need assistance with visualization of material or alternate format? Yes No Number of arrest in the past 30 daysDoes client have any disabilities that would require someone else to make decisions for them? Yes No Convictions or charges we should be aware ofList name, address and phone numberPAYERMedicaid NumberMedicare NumberPrimary Private InsuranceInsurance Plan NumberGroup NumberName of Policy Holder (as it appears on the card)Date of birth of policy holder MM slash DD slash YYYY SSN of policy holderSecondary Private InsuranceInsurance Plan NumberGroup NumberCompany NameNumber of visitsSecondary Private Insurance EAP Involved/Eligible Workers Compensation Veteran/Military Service Self Other Specify Demographic Form