Cognitive Consultants, LLC. Client Information Date of Intake: * MM DD YYYY Intake Worker: First Name Last Name Client Name: * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Sex * Male Female Current Charge/Crime Briefly describe the current charge or crime if applicable. Judge: Probation Officer: First Name Last Name Social Security Number Race * White Black Native American Asian Alaskan Native Other Ethnic Background Puerto Rican Mexican Cuban Other Hispanic Arab/Caldean Other Education: Highest Grade Completed: K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Degree Received: Diploma G.E.D None College Completed Bachelor's Master's None Major: Marital Status * Never Married Married Separated Divorced Widowed Co-Habitating Family Structure You may click more than one option if it applies to your situation. For example, if you are a parent and live with your parents, check off both 'Single Parent' and 'Living With Parents'. Couple Single Adult Living with Parents Single Parent Step Family Employment Status * Full-Time Part-Time Student Disabled Retired Unemployed - Looking for Work Unemployed - Not in Workforce Laid Off Homemaker Employer Position Source of Income Job Spouse Family Public Assistance Pension Other (Enter Below) If "Other" was selected, please enter the source of income here: Number of Dependents: Emergency Contact * First Name Last Name Relationship Phone (###) ### #### Doctor's Name: Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Program Name: Date MM DD YYYY Intensive Phase I Individual Other DV Thank you! Your Client Information Form was sent successfully.
