Jeff Peterson - Primary Client Information

Primary Client Information

Please fill out the information below for you and those who will be attending counseling with you. You may skip over questions that are not relevant. Fields with a red asterisk are required.
Please Select the Name of your Clinician *
Your Name *

First Name Last Name
Your Date of Birth *

Month Day Year
Preferred Gender Pronouns (optional)
E-mail
Partner's Name (for Relationship Therapy)

First Name Last Name
Patient's Name (if other than self)

First Name Last Name
Address *

Street Address Line 1

Street Address Line 2

City State

Zip Code Country
Phone Number *

Area Code Phone Number
Patient's Phone (if different)

Area Code Phone Number
Primary Partner's Address (if different than yours - for Relationship Therapy)
Current Romantic Relationships
For Multi-Person Relationships - Additional Partners' Information (if relevant):
Emergency Contact Name *

First Name Last Name
Emergency Contact Relationship
Emergency Contact Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Should be Empty: