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ERK4499 - SECTION 6: THE FACE SHEET

 

Section 6: The Face Sheet

A face sheet can be used in a number of different ways. First, it can be placed in the front of a case record in order to make it easier to find the contact or insurance information for the client. This can be more convenient in terms of finding contact information more quickly. Some clinicians may choose to have the face sheet information contained both within the body of the assessment form, and duplicating this same information on a separate sheet more conveniently located in the very front of the clinical record.

There is one other circumstance in which a face sheet has a more important purpose. Some organizations prefer to separate case information from client identifying information in order to offer a slightly higher degree of privacy to the client. In such instances, the client’s records are assigned a case number, which is recorded on the face sheet. The face sheet is then kept in a separate location from the clinical records. Both the records and the face sheet are typically kept in separate, secure locations. Should a breach of security occur in either of the two locations, it improves the odds that client identifying information cannot be connected up with the clinical facts of the case.

There are face sheets designed for work with individual clients and face sheets designed for instances in which there are multiple clients, i.e., couples or family therapy. For simplicity’s sake, it may be helpful to design a face sheet that can address both possibilities. An example of such a face sheet is shown on the next page.

For instances in which there are more than two clients, it may also be helpful to add a second page to your face sheet in order to gather the relevant information. This option is shown on the second page to follow.



Face Sheet                                                Privacy #: _________________


Client Name: _________________ DOB:__________   Sex: ___M ___F
Address: _____________________City/State/Zip: _____________________
Home Phone:__________________ Work Phone:______________________ 
Cell phone: _______________Email Address:__________________________
Emergency Contact: _________________Contact Phone: ________________
Name of PCP:______________________ PCP Phone:___________________ 
PCP Address:_________________ City, State, Zip:______________________ 
Client is: ___Married ___Single ___Other ___Employed ___Full-time Student ___Part-time Student

Insurance Information

Insurance Plan:_________________ Insurance ID#:____________________ 
Insurance Group#:_______________ Insured’s Employer:________________ 
Client’s relationship to insured: ___Self* ___Spouse ___Child ___Other: ____________________________
*If you checked “Self” above, leave these blank
*Insured’s Name:__________________ *DOB:___________ *Sex: ___M ___F
*Address:______________________ *City/State/Zip:____________________ 
Is there a second insurance plan? ___Yes ___No If yes, fill out information below for second insurance plan
Insurance Plan:____________________ Insurance ID#:___________________ 
Insurance Group#:__________________ Insured’s Employer:______________ 
Insured’s Name:____________________ Insured’s DOB:__________________ 
Address:_____________________ City/State/Zip:________________________ 

If coming to treatment for couples/family counseling, please list information for co-client(s):
Client Name:__________________________ Relationship to above:_________ 
Address:__________________ Town/State/Zip:__________________________ 
Home Phone:______________ Work Phone:____________________________ 
Cell phone:________________ Email Address:__________________________
Emergency Contact:___________________ Contact Phone:________________ 
Name of PCP:________________________ PCP Phone:__________________ 
PCP Address:________________ City, State, Zip:________________________ 




Face Sheet (page 2 for additional multiple clients)


If coming to treatment for couples/family counseling, please list information for co-client(s):

Client 3 

Client Name:__________________________ Relationship to above:_________ 
Address:__________________ Town/State/Zip:__________________________ 
Home Phone:______________ Work Phone:____________________________ 
Cell phone:________________ Email Address:__________________________
Emergency Contact:___________________ Contact Phone:________________ 
Name of PCP:________________________ PCP Phone:__________________ 
PCP Address:________________ City, State, Zip:________________________


Client 4 

Client Name:__________________________ Relationship to above:_________ 
Address:__________________ Town/State/Zip:__________________________ 
Home Phone:______________ Work Phone:____________________________ 
Cell phone:________________ Email Address:__________________________
Emergency Contact:___________________ Contact Phone:________________ 
Name of PCP:________________________ PCP Phone:__________________ 
PCP Address:________________ City, State, Zip:________________________


Client 5 

Client Name:__________________________ Relationship to above:_________ 
Address:__________________ Town/State/Zip:__________________________ 
Home Phone:______________ Work Phone:____________________________ 
Cell phone:________________ Email Address:__________________________
Emergency Contact:___________________ Contact Phone:________________ 
Name of PCP:________________________ PCP Phone:__________________ 
PCP Address:________________ City, State, Zip:________________________

 

 

 

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