Personal Client Info Sheet

PERSONAL CLIENT INFORMATION SHEET

Client Identification

Date of Birth:    Preferred Name:    Pronouns:

Emergency Contacts

Medical & Health Information

Primary Care Provider:    Preferred Hospital:

Employment & Financial (Optional)

Legal Representatives & Authorizations

Does the client have a designated legal representative or agent (power of attorney)?   Yes   No

Communications & Privacy Consent

By checking the box below and signing this form, the client grants authorization to collect, maintain and disclose the personal information supplied on this form to third parties only as necessary for the provision of services, emergency response, billing, and legal compliance. The client understands that information will be retained in accordance with standard record retention practices and that they may request correction or revoke consent in writing.

I consent to the collection, use, and limited disclosure of my personal information as described above.

Phone    Email    Postal Mail    Text Message

Accessibility & Accommodations

Statements & Certification

I certify that the information provided on this form is true, complete and accurate to the best of my knowledge. I acknowledge that knowingly providing false information may affect eligibility for services and may have legal consequences. I agree to notify the organization promptly of any changes to this information.

I understand that this form does not by itself create a power of attorney or other durable legal instrument unless explicitly identified and executed as such under separate documentation.

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