Karen Straub, LICSW

Telehealth Psychotherapy Services for adolescents & adults

Karen Straub, LICSW

5 Market Square #204

Amesbury, MA 01913



CLIENT INFORMATION



Client NAME:

Parent/guardian Name if a Minor:


ADDRESS:



DATE OF BIRTH:


PHONE:

Home:

Cell:

Can I text you for appointment confirmation/change?


EMAIL:


Preferred Method of Communication:   text?    phone call?     email?


INSURANCE INFO:

Company:

ID #:

Subscriber Name:

Subscriber Address:


Subscriber DOB:


HAVE YOU BEEN IN THERAPY BEFORE?

If so, with whom?

Was it helpful to you?


ARE YOU CURRENTLY TAKING ANY MEDICATIONS?

Med:

Dosage:

Med:

Dosage:

Med:

Dosage:


Who prescribes these medications?

May I contact this person with a signed release of information form?






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