Client Registration Form

Date

Name *

First

Last

DOB

Address

City

State

ZIP

Telephone

Work #

Emergency Contact Name

Emergengy Contact Number

Please take time to respond to the following questions if applicable: 1) What brings you to treatment at this time?

2) Describe any symptoms you may be having at this time (for instance, sleeplessness, panic, unusual thoughts)

3) Have you had counseling in the past?

4) Please list all other providers involved in your care at this time (primary care, specialists)

5) Please list any current medications

6) Do you have any legal involvement at this time?

Website

susan.elliottlicsw@gmail.com

Fax: (978) 532-0200

National Provider Identifier: 1831315126

Member of National Association Of Social Workers, MA Chapter

MA License: 1026J08