Patient Name*

DOB*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone*

Cell Phone*

Email*

Birth Information

Birth Date*

City of Birth*

Country of Birth*

Sex*

Ethnicity*

Religion*

Language(s)*

Marital Information

Marital Status*

Date of Marriage*

Spouse’s Name*

Attorney Information

Name*

Address*

Office Phone*

Fax*

Family Members Living With You

Name*

Relation*

Place & Date of Birth*

Occupation / Education*

Employment History (list all jobs, starting with current)

Employer*

Position*

Responsibilities*

Dates of Employment*

Immigration History

Are you a U.S. Citizen?

Yes

Date you entered the U.S.*

How did you enter the U.S.*

With whom did you enter*

Please share your reasons for coming to the U.S.*

Legal History

Have you ever been arrested or detained?*

Yes

Please Describe:*

Have you ever been the victim of a crime?*

Yes

Please Describe:*

Name*

Date*

Address*

Home #*

Mobile #*

Type of information to be released: Psychological and Behavioral Information Purpose of release: Psychological Evaluation and Current Functioning Assessment between attorney and assigned therapist at Integral Mental Health Counseling, PLLC To / From (Attorney)*

I authorize the periodic disclosure and use of the information specified above to the person identified, as needed to coordinate any treatments or testing. I understand I have the right to revoke this consent at any time. My consent to release information to the person/service named above will expire when I am no longer receiving services or one year from the date below, whichever occurs first

Name*

Date*

Immigration Form