Whitney Cain PHD

Bloomsbury Therapy PLLC

YOU BLOOM CARDS

FORMS/POLICIES

Client Information Form

Client Checklist & Concerns

Fees & The No Suprises Act

Whitney Cain PHD

Bloomsbury Therapy PLLC

YOU BLOOM CARDS

FORMS/POLICIES

Client Information Form

Client Checklist & Concerns

Fees & The No Suprises Act

Client Information Form

Client Information Form

Name *

First Name

Last Name

Email Address *

Street Address

City, State & Zip Code

Home Phone

(###)

###

####

May we leave a message?

Yes

No

Cell Phone

(###)

###

####

May we leave a message?

Yes

No

Work/Other Phone

(###)

###

####

May we leave a message?

Yes

No

Date of Birth

MM

DD

YYYY

Relationship Status

Single

Domestic Partnership

Married

Committed Relationship

Separated

Divorced

Widowed

Other

Children (Names & Ages)

Are you currently employed?

Yes

No

If yes, please note your job title and employer.

Have you received mental health previously? If so, please provide dates and practitioner names.

Please indicate if there is a family history of any of the following.

Alcohol/Substance Abuse

Anxiety

Depression

Domestic Violence

Eating Disorders

Obesity

Obsessive Compulsive Behavior

Schizophrenia

Suicide/Suicide Attempts

Referral

How did you find out about Bloomsbury Therapy/Dr. Whitney Cain?

Comments/Questions

Thank you for completing and submitting these forms. I look forward to meeting with you.

Best,

Whitney Cain, PhD