David A. Yeats M.S.W., L.C.S.W.
Psychotherapy and Consultation Services
350 Broadway, Suite 102
Boulder Colorado 80305
(303) 335.9170
www.DavidAYeats.com
DAYeatsMSW@Hotmail.com
Colorado License # 989213   EIN 84-1253608   NPI 1578702254

CLIENT INFORMATION


Please provide the following information for each individual:

Name ________________________________________________ Today’s Date ___________________________
Date of Birth _________________________       Social Security Number _________________________________
Referred by: _________________________________________________________________________________

Email Address _______________________________________________________________________________
Home Phone ____________________________                          Work Phone _____________________________
Cell Phone _____________________________                           Other Phone _____________________________
Street Address _______________________________________________________________________________
City __________________________________________              State __________ Zip _____________________
Mailing Address (if different) _____________________________________________________________________
City __________________________________________              State __________ Zip _____________________

Employer Name _______________________________________________________________________________
Employer Address _____________________________________________________________________________
City __________________________________________              State __________ Zip _____________________

Credit Card Information (if paying by CC):     ____                       Visa      ____MasterCard       ____Discover     ____AmEx
Name (as on card) ________________________                        Card #: __________________________________
Exp. Date (Month/Year):  ________                                           3 (or 4)-digit code _________        Zip on Card __________          


If you are currently involved in any other treatment, including treatment for psychotherapy (individual, couple, or group), psychiatry or medication management, relevant other medical conditions, pain management, acupuncture, chiropractics, etc, please indicate the names of each clinician and the purpose of treatment. (At some point, it may be useful to talk with other providers, and you may be asked to sign a release).

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If you are currently taking any prescribed psychiatric medication, please list med, prescribing physician, dosage and purpose. ¬

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