Dr. Jain Fairfax, Marriage & Family Therapist

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Counseling and psychotherapy for individuals, couples and families.

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Licensed Marriage Family Therapist CA 25636

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Please fill out ALL information, then submit.

CLIENT INFORMATION, CONSENT, AND DISCLOSURE STATEMENT

Name:

Age

Date of Birth

Address

Phone (home):

Phone (work):

Phone (cell):

Fax:

Email:

If you do not wish to be emailed, please let Dr. Fairfax know. Email can be used to set and/or confirm appointments.

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By checking, I give Dr. Fairfax permission to use Facetime, Skype, or Zoom for teletherapy and to contact me using the internet.

REFERRED BY:

New Field:

Living situation:

Single

Married

Partnered

Divorced

Separated

Widowed

Other

Prior counseling

Outcome of prior counseling

Medical issues:

Medications

Drug or alcohol use:

Daily

Weekly

In/have been in treatment

Other substances:

Daily use

Weekly use

In/have been in treatment

Treating physician:

Physician's phone:

In emergency call:

Emergency Contact's phone:

Relationship:

Free Text

Payment/Insurance

Insurance Company

Claims address

Claim # or Case #

Claim phone

Policy #, Plan/Program#

Group# Employer/school

Insured's Name

Date of birth

Relation

Other insurance?

Type: (check one)

Group Workers Comp

Auto injury

EAP

Victim of Crimes

Other

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707-526-2580

contact@drjainfairfax.com

2455 Bennett Valley Road, B-208, Santa Rosa, CA 95404

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