Home
Templates
Form
Client Intake Form
Free Client Information Form Template

Free Client Information Form

Name: Free Client Information Form Template
Brand: Template.net
Availability: InStock

Client Information Form

Please complete this Client Information Form Template to gather and record essential details about your clients, including contact information, preferences, and business needs.

Date

A. Identification

Full Name

Date of Birth

Email

Phone number

Address

May we send you a message?

May we leave a message?

B. Referral Information

Name

C. Medical Care

Clinic/Doctor's Name

Phone number

Address

D. Current Employer Information

Employer Name

Address

Job Title and Duties

E. Education and Training

	Form	To	School	Major	Adjustment	Graduate
1
2

Thank you for submission!

We appreciate you taking the time to submit.

Create free forms at Template.net Sheet Templates @ Template.net Sheet Templates @ Template.net Sheet Templates @ Template.net

F. Health and Mental Health Information

Have you previously received any type of mental health services?

Are you currently taking any prescription medication, including anti-depressants?

How would you rate your current physical health?

Poor
Unsatisfactory
Satisfactory
Good
Very Good

How would you rate your current sleeping habits?

Poor
Unsatisfactory
Satisfactory
Good
Very Good

How often do you engage in recreational drug use?

Daily
Weekly
Monthly
Infrequently
Never

G. Emergency Information

Name

Phone number

Significant/nearest friend or relative not living with you

H. Financial Information

Insurance Company

Phone number

Policy #

Group #

Name of Insured

Relationship of Insured

Insured's Date of Birth

This is strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.

Sheet Templates @ Template.net

Free

Edit this free template

No sign up needed

100% Customizable, free editor
Access 1 Million+ Templates, photo’s & graphics
Download or share as a template
Click and replace photos, graphics, text, backgrounds
Resize, crop, AI write & more
Access advanced editor

AI Form Builder Generator

Generate my free Form Builder

Text or voice to generate a free Form Builder

Effortlessly collect and organize client data with Template.net's Client Information Form Template. This fully customizable and editable form allows you to tailor information fields to suit your business needs. With the AI Editor Tool, you can easily modify the template for efficient client management. Download and start customizing your client information forms today for seamless data collection!