Demographics Form Thank you for your interested in my services. Please complete the following form with the intended client’s information. If you are interested in couples therapy, please complete a form for both individuals. This information will be emailed directly to Jenn Teutscher. I look forward to working with you! Legal First and Last Name(required) Todays Date Date of Birth(required) Address(required) Email(required) May I contact you via email?(required) Yes No May I email you forms through Adobe Acrobat Sign?(required) Yes No Phone Number(required) May I contact you on this number?(required) Yes No Insurance Provider/Plan Name Insurance Patient ID How did you hear about me? If client is MINOR, person responsible/guardian (please identify NAME, RELATION, AND PHONE NUMBER). Emergency Contact Information Emergency Contact Name(required) Relationship to Emergency Contact(required) Emergency Contact Phone Number(required) Identity Information Ethnicity/National Origin Current Religious Denomination/Affiliation Religious/Spiritual Involvement None Some/Irregular Active Gender Identity Female Male Transgender Non-binary Gender Neutral Pangender Genderqueer Sexual Orientation Asexual (lack of sexual interest in either men or women) Bi-Sexual (sexual interest in both men and women) Gay/Lesbian (sexual interest in a member of the same sex) Heterosexual (sexual interest in a member of the opposite sex) Questioning (still exploring or unsure of sexual orientation) Other related way you identify yourself and consider important Send Δ
Jenn Teutscher, LMFT 