Client Face Sheet-2011 - Centus Counseling Center - centus-2026

1. Click ‘Get Form’ to open the Client Face Sheet in the editor.
2. Begin by filling in your name in the designated fields for First, Middle, and Last names. Ensure all information is printed clearly.
3. Provide your street address, city, county, state, and zip code. Make sure to include both home and cell phone numbers for contact purposes.
4. Indicate your gender by selecting from Male, Female, or Transgender options. Next, select your race/ethnicity from the provided list.
5. Enter your Social Security Number and Date of Birth accurately. This information is crucial for clinical purposes.
6. Select your current marital status and provide details about your religious background if applicable.
7. Fill in your age and gross family income range to assist with data collection for grant writing.
8. Complete the referral data section by noting who referred you and their relationship to you.
9. In case of an emergency, provide contact details for two individuals who can be reached on your behalf.
10. Finally, sign the document along with a parent or legal guardian if necessary. Don’t forget to include the date of signing.

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