Full Name
Today's Date
MaleFemale
Date of Birth
Age
Home Address
City
State
Zip Code

Home Telephone
Email Address
Is it OK to contact you at home?
OK to leave a message?
Mobile Telephone
Is it OK to contact this number?
OK to leave a message?

Reason for seeking treatment:

Please briefly describe the problems you are experiencing.
What has happened to cause you to seek help now?
What do you hope to be able to do or achieve as a result of treatment?
Do you currently have thoughts of harming yourself?YesNo
Have you in the past?YesNo
If Yes, how long ago?
Do you currently have thoughts of wishing you were dead?YesNo
Do you currently have urges to hurt, harm, or kill someone else?YesNo
If yes, whom?
Name, address, phone number and fax number of your Psychiatrist:
Have you ever been treated, or have you ever had previous therapy/counseling of any kind?YesNo
If yes, when, with whom, and for how long?
Have you been hospitalized for emotional problems?YesNo
Or for substance abuse problems?YesNo
If yes to either of above, please state when, where, and for how long were you hospitalized (Please consider having recent records forwarded to this office),

Substance Use History:

Have you ever experienced a problem with alcohol, drugs, or prescription medications?YesNo
If yes, please explain

Family Background:

List the name of your children and their ages
1.
2.
3.
4.
5.
Whom were you raised by (Please indicate their name)?
Describe your relationship with your parents briefly
Has anyone in your family ever attempted or committed suicide?YesNo
If yes, please explain:

Marital Status:

Marital/relationship status ( Check one )MarriedLive with PartnerSingleSeparated/DivorcedWidowed
Or other
Have you ever been abused mentally or physically by a romantic partner?YesNo
Does this apply to your current relationship?YesNo
Do you feel safe?YesNo

Employment/Education Information:

Check all that apply: EmployedRetiredDisabledStudentHomemakerUnemployed
If/When employed? What do you do?
Current employer is:
Your Current job:
Your income:
Total Household income:
Highest degree completed in school:

Health/Medical Information:

Please list significant medical problems/conditions, and indicate if you are receiving treatment for them:

Briefly describe any surgeries or hospitalization for serious illness or injuries (What, Where, When, etc.):

If you ever blacked out/ lost consciousness and/or experienced any type of serious head injury or trauma?YesNo
If so, indicate when and what happened?

Do you have a history of the following?

List all medications that you currently use (Please feel free to attach additional sheets as necessary):
Medication(s)

Dosage (Amount and time per day)

Reason(s)
Name, Address, Phone Number and Fax of Primary Care Physician (PCP):

What was the date of your last complete physical that included labwork?

Please indicate Name, Address, Phone Number and Fax of the doctor who completed the last physical and the results

Please indicate a person who give this office permission to contact in the event of a life-threatening emergency. This two individuals should be aware that you are seeking mental health treatment.

If case of emergency, please notify:

1. Name
2. Relationship
3. Cell Phone Numbers
4. Home Phone Numbers

Patient Statement: “I agree that the above information is true to the best of my knowledge. And, I give permission for my treating Psychologist to collaborate with all medical providers listed in this document as it relates to my continuing mental health and/or medical care. I can modify/revoke this decision at any time if I submit a request in writing.”

Patient Name Printed/Date

Patient Signature/Date

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