NEW LIFE COUNSELING SERVICES

389 Waller Ave, Ste. 200/220

Lexington, Kentucky 40504
859-3092384
CLIENT INFORMATION PHONE LOG
CLIENT NAME: _______________________________D.O.B.: ___/___/___Prefered Pronoun: M / F / other:_______

SOCIAL SECURITY NUMBER: ___________________________

EMAIL ADDRESS: _____________________________________ PHONE: __________________________

ADDRESS: _____________________________________________________________________

CITY: ______________________________________STATE: _________________ZIP: _________________

INSURANCE COMPANY: _______________________________MEMBER ID #: ________________________

Eligibility Effective Date: ________________ Mental Health Benefits: _______________

# of sessions allowed: __________is Prior Authorization Needed? Y/N
Co-pay: ________ Deductible: _____________ Remaining: _______________ Co-insurance: __________

POLICY HOLDER: _________________________________D.O.B.: ____/___/___ SEX: M / F

RELATIONSHIP TO THE CLIENT: _________________________

TREATMENT
CONCERNS:_______________________________________________________________________________________
_______________________________________________________________________________________

PRIOR HISTORY OF COUNSELING? Y/N

IF SO WITH WHOM? ___________________________HOW LONG? _______________________________

AVAILABILITY FOR TREATMENT: We are open Monday-Friday 8:00-6:00 and weekends by appointment only.
Please be list specific times. Sessions begin on the hour. For example, AM 8-10, PM 4-6
M MON. TUES. WED. THURS. FRI. SAT. SUN.

AM
PM

Assigned Counselor:_______________________Date:___________________Time:_________________

REFERRED BY: _____________________________Date of call: ____________________________