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Wentworth and Associates, P.C.
11111 Hall Road, Suite 303
Phone (586) 997-3153
Fax (586) 997-4956
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Birth Sex:
*
Address:
City:
State:
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Zip Code :
Phone No:
PLEASE COMPLETE AS MUCH OF THIS FORM AS POSSIBLE AND PUT N/A IN ANY FIELD WHERE YOU ARE UNSURE OF THE ANSWER
*PLEASE BE AWARE THAT THERE IS VERY LIMITED SERVICES AVAILABLE IN PERSON OR FOR CHILDREN/ADOLESCENTS AND NO PSYCHOLOGICAL TESTING OR COURT ORDERED TREATMENT AT THIS TIME. PLEASE CALL MACOMB FAMILY SERVICES 586-226-3440 OR BIRMINGHAM MAPLE CLINIC 248-646-6659 FOR TREATMENT FOR YOUNG CHILDREN,TESTING,OR COURT ORDERED CASES.
* Today's Date:
Are you already scheduled with a clinician? If, so, please least clinician name:
* Who is submitting this form?
If a minor client, please list legal guardians:
Guardian 1
Name:
Address:
Address Line 2:
City:
State:
Select A State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
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Louisiana
Maine
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Massachusetts
Michigan
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Mississippi
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New Hampshire
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New Mexico
New York
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North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Alberta, Canada
British Columbia, Canada
Manitoba, Canada
New Brunswick, Canada
Newfoundland / Labrador, Canada
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ontario, Canada
Prince Edward Island, Canada
Quebec, Canada
Saskatchewan, Canada
Yukon, Canada
Australian Capital Territory, Australia
Jervis Bay Territory, Australia
New South Wales, Australia
Northern Territory, Australia
Queensland, Australia
South Australia, Australia
Tasmania, Australia
Victoria, Australia
Western Australia, Australia
Guanacaste, Costa Rica
Alajuela, Costa Rica
Heredia, Costa Rica
San Jose, Costa Rica
Cartago, Costa Rica
Limon, Costa Rica
Puntarenas, Costa Rica
Zip Code:
Phone:
(Home)
(Business)
(Cell)
Relationship:
Email:
Guardian 2
Name:
Address:
Address Line 2:
City:
State:
Select A State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Alberta, Canada
British Columbia, Canada
Manitoba, Canada
New Brunswick, Canada
Newfoundland / Labrador, Canada
Northwest Territories, Canada
Nova Scotia, Canada
Nunavut, Canada
Ontario, Canada
Prince Edward Island, Canada
Quebec, Canada
Saskatchewan, Canada
Yukon, Canada
Australian Capital Territory, Australia
Jervis Bay Territory, Australia
New South Wales, Australia
Northern Territory, Australia
Queensland, Australia
South Australia, Australia
Tasmania, Australia
Victoria, Australia
Western Australia, Australia
Guanacaste, Costa Rica
Alajuela, Costa Rica
Heredia, Costa Rica
San Jose, Costa Rica
Cartago, Costa Rica
Limon, Costa Rica
Puntarenas, Costa Rica
Zip Code:
Phone:
(Home)
(Business)
(Cell)
Relationship:
Email:
Additional client information
* Social Security Number
* What phone number should we use? (If different from above)
* May we send texts to the phone number listed?
Yes
No
* E-mail address for correspondence and billing:
* Who is responsible for treatment billing matters?
Language
Abkhazian
Afar
Afrikaans
Akan
Albanian
Amharic
Arabic
Aragonese
Armenian
Assamese
Avaric
Avestan
Aymara
Azerbaijani
Bambara
Bashkir
Basque
Belarusian
Bengali
Bihari languages
Bislama
Bokm�l, Norwegian; Norwegian Bokm�l
Bosnian
Breton
Bulgarian
Burmese
Catalan; Valencian
Central Khmer
Chamorro
Chechen
Chichewa; Chewa; Nyanja
Chinese
Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic
Chuvash
Cornish
Corsican
Cree
Croatian
Czech
Danish
Declined to Specify
Divehi; Dhivehi; Maldivian
Dutch; Flemish
Dzongkha
English
Esperanto
Estonian
Ewe
Faroese
Fijian
Finnish
French
Fulah
Gaelic; Scottish Gaelic
Galician
Ganda
Georgian
German
Greek, Modern (1453-)
Guarani
Gujarati
Haitian; Haitian Creole
Hausa
Hebrew
Herero
Hindi
Hiri Motu
Hungarian
Icelandic
Ido
Igbo
Indonesian
Interlingua (International Auxiliary Language Association)
Interlingue; Occidental
Inuktitut
Inupiaq
Irish
Italian
Japanese
Javanese
Kalaallisut; Greenlandic
Kannada
Kanuri
Kashmiri
Kazakh
Kikuyu; Gikuyu
Kinyarwanda
Kirghiz; Kyrgyz
Komi
Kongo
Korean
Kuanyama; Kwanyama
Kurdish
Lao
Latin
Latvian
Limburgan; Limburger; Limburgish
Lingala
Lithuanian
Luba-Katanga
Luxembourgish; Letzeburgesch
Macedonian
Malagasy
Malay
Malayalam
Maltese
Manx
Maori
Marathi
Marshallese
Mongolian
Nauru
Navajo; Navaho
Ndebele, North; North Ndebele
Ndebele, South; South Ndebele
Ndonga
Nepali
Northern Sami
Norwegian
Norwegian Nynorsk; Nynorsk, Norwegian
Occitan (post 1500)
Ojibwa
Oriya
Oromo
Ossetian; Ossetic
Pali
Panjabi; Punjabi
Persian
Polish
Portuguese
Pushto; Pashto
Quechua
Romanian; Moldavian; Moldovan
Romansh
Rundi
Russian
Samoan
Sango
Sanskrit
Sardinian
Serbian
Shona
Sichuan Yi; Nuosu
Sindhi
Sinhala; Sinhalese
Slovak
Slovenian
Somali
Sotho, Southern
Spanish; Castilian
Sundanese
Swahili
Swati
Swedish
Tagalog
Tahitian
Tajik
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Tatar
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Tsonga
Tswana
Turkish
Turkmen
Twi
Uighur; Uyghur
Ukrainian
Urdu
Uzbek
Venda
Vietnamese
Volap�k
Walloon
Welsh
Western Frisian
Wolof
Xhosa
Yiddish
Yoruba
Zhuang; Chuang
Zulu
Cultural Identification/Heritage
Veteran
No
Yes
Gender Identification
Ambiguous
Female
Male
NOT APPLICABLE
OTHER
Transgender (Female Pronouns)
Transgender (Male Pronouns)
Unknown
Marital Status
Divorced
Long-term Civil Union
Married
Separated
Single
Widowed
If client is in treatment outside the clinic at time of intake, please provide name and phone number of treatment provider
General Status
Disabled
Employed
Refused
Retired
Senior
Student
Unemployed - Seeking Employment
Unemployed - Unable to Work
Other:
GENERAL
* What are the concerns that you would like addressed in treatment?
Have you received assistance from us before?
Yes
No
Are you looking for a specific kind of treatment? If so, please list.
Client preference for therapist:
Female
Male
* Days/times you and/or your spouse or your child is/are available for treatment(please keep in mind evenings and weekends are limited):
* Are you willing to participate in telehealth? (please keep in mind there are a limited amount of in-person therapists)
Yes
No
* Referral Source:
Another therapist/agency
Friend/family
Healthcare Provider
Internet
Non-profit organization
Other
School
Other Referral Source:
Safety
* Having suicidal/homicidal ideation at time of intake?
Yes
No
Any medical concerns that may affect treatment? If yes, please list.
* Any history of substance abuse? If so, what and when?
Please describe your substance use.
Any legal issues that may effect treatment? If so, please list.
Insurance and Financial Information
* Insured?
Does the patient have insurance?
Yes
No
* Insurance Name:
* Insurance Address:
* Insurance City, State and ZIP:
* Insurance Phone:
Insurance Effective Date:
* Policy Number:
* Group Number:
* Subscriber name:
* Subscriber date of birth:
Medicare Number:
Medicaid Number:
Additional comments:
Form Updates
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