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Reviewing Paperworks

Client Paperwork

Welcome to Community Counseling Center! To ensure we can provide you with the best possible care, please take a moment to complete our new client paperwork. This information helps our team understand your needs and tailor our services to support your well-being. You can download and fill out a copy of the paperwork here, or complete it electronically through the form below.

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Need help? Contact us.

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Community Counseling Center

Confidential Client Paperwork

 

Today's Date

Contact Information

May CCC Staff leave a voice message?
If YES, please specify:

Emergency Contact

Please include your emergency contact in your release of information form.

Referral Information

What agency or person referred you to us?

Demographic Information

The questions below are for demographic/funding purposes only.  Please mark the appropriate category.

Race
Are you Hispanic, Latin, or of Spanish ethnicity?
Yes
No
I prefer not to answer
If Yes, please answer the question below:
How do you identify yourself?
Are you pregnant?
Yes
No
What is your orientation?
Have you ever used drugs intravenously?
Yes
No
Have you ever been tested for HIV?
Yes
No

Financial/Insurance Information

Are you currently employed?
Yes
No
Do you have health insurance/Medicaid?
Yes
No
Have you ever received services at this agency?
Yes
No
Are you receiving services somewhere else?
Yes
No

Intake/Client Concerns


The following information will assist us in recommending a treatment program that will best meet your needs. This is confidential information and will not be released without written consent. Please feel free to take your time in answering the following questions.

What services does your REFERRAL SOURCE wish you to receive from CCC?
What services do YOU wish to receive from CCC?
What topics are you interested in exploring with a counselor?
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