CLIENT SCHOOL INFORMATION
Client Information Form
Length: About 10 minutes
DO NOT LEAVE THE PAGE. YOU CANNOT SAVE AND COME BACK LATER. COMPLETE ALL THE BOXES. WHEN FINISHED, CLICK THE BUTTON [SUBMIT] TO SEND YOUR INFORMATION CONFIDENTIALLY TO WICKS PSYCHOLOGICAL SERVICES.
ALL INFORMATION IS REQUIRED - IF AN ITEM DOES NOT APPLY, KEY IN N/A.
Child/Adolescent under 19 years of age
CLIENT PROPER NAME
BIRTH DATE (MM/DD/YYYY)
HOME PHONE NUMBER
CELL PHONE NUMBER
REQUIRED: Please enter your first and last name to complete the form. Please complete all fields. Enter "na" if not applicable.
CLIENT EMPLOYMENT INFORMATION
IF YOU SELECTED "SCHOOL,"
THEN ENTER A GRADE HERE.
CONSENT FOR TREATMENT
PROCEED TO GIVE CONSENT:
All information sent is held as strictly confidential.
1). CHECKBOX Click this box to indicate: "Yes I give consent"
2). SIGNATURE BOX "My full legal name will act as my signature."
3). SUBMIT BUTTON
4). RESULT MESSAGE
If for any reason an appointment cannot be kept, please notify the Wicks Psychological Services Office at least 24 hours in advance. Unless the cancellation is due to an emergency, there will be a charge for the time that was reserved for you. This is at the discretion of your doctor.
1). Click on the [CHECKBOX] to display a check mark.
2). Click on the [SIGNATURE BOX] to type in your full legal name.
3). Click on the [SUBMIT] button once to send this form.
4). The [RESULT MESSAGE]. If the submission was good, then the Result Message will display as. . .
"This form has been submitted successfully."
If there is any error on the page, the Result Message
will display as. . .
"OOPS! There is an error somewhere. Fix those and
come back to submit again."
The appearance of red boxes means the information is required, but the box is empty. If the item does not apply, type in "na."