Client Information

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321 West Walnut Street

Johnson City, Tennessee 37604

Tri Cities Behavioral Therapy

Tel: 423-202-3622

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Tri-Cities Behavioral Therapy 321 West Walnut Street Box#2

Johnson City, Tennessee 37604

Phone: 423-202-3622

Fax: 423-631-0019

Please fill in all required ( * ) fields.

Date

Client Last Name

Middle Initial

Birthdate

Client First Name

Age

Gender

Parent/Guardian Name

Ok to send letter

Primary Language

Address

Race/Ethnicity

Home Phone#

OK to call Home Number

Yes

No

Mobile Phone#

OK to call Mobile Number

Yes

No

Work Phone#

OK to call Work Number

Yes

No

Other Phone#

OK to call Other Number

Yes

No

If no how can you be reached?

Martial Status

Does Client Have Children

Number of people living in Client's home.

Please list members of household, their ages, and relationship to client

Emergency Contact Person

Emergency Contact Relationship to Client and Phone Number.

Physician Information

Physicians Name

Physicians Phone#

Physicians Address

Current Diagnosis

Insurance Information

Clients Name and Social Security Number

Parents Name and Social Security Number

Primary Insurance

Primary Insurance Company

Primary Insurance Group Number

Primary Insurance Subscriber's Name

Primary Insurance Subscriber's Date of Birth

Primary Insurance Policy Number

Primary Insurance Member ID

Primary Insurance Employer

Primary Insurance Subscriber's Relationship to Client

Secondary Insurance

Secondary Insurance Company

Secondary Insurance Group Number

Secondary Insurance Subscriber's Name

Secondary Insurance Subscriber's Date of Birth

Secondary Insurance Policy Number

Secondary Insurance Member ID

Secondary Insurance Employer

Secondary Insurance Subscriber's Relationship to Client

Medical History

Current Medications and Why They are Prescribed

Past Medications and Why They are Prescribed

Food or Drug Allergies

Physician Exam in the Last Year

Is the Client currently seeing a Psychiatrist, Psychologist, Social Worker, or Counselor? If yes list their name (s)

Other providers involved with your child’s care (PT, OT, Speech, etc)

For patient: past or current history and/or treatment for any of the following:

Patient History 1

Stroke

Asthma

Anemia

Eating Disorder

Communicable Diseases

Vision problems

Menstrual Difficulties (females only)

Seizures

Hepatitis

Hypertension

Patient History 2

Diabetes

Tuberculosis

Cardiac Problems

Urinary Tract Infections

Weight Loss

Hearing problems

Sleep issues

Respiratory

Cancer

Skin rashes

For Patient any other past or current history and / or treatments.

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Family History

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