Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:
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1 Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax: Please complete the following so I can have a better understanding of how I can help you. GENERAL INFORMATION Date: Full Name: Mr. Mrs. Ms. Miss Social Security: Age: Date of Birth: Race: White Black Hispanic Asian Other: Sex: Male Female Relationship Status: Single Married Divorced Separated Insurance Yes No Insurance Company: Insurance ID#: Authorization#: Insurance Address: Availability (Days,Times): CONTACT INFORMATION Address: City: State: Zip Code: May We Send Mail Here: Yes No Home Phone: ( ) Mobile Phone: ( ) Work Phone: ( ) May We Leave a Message Here: Address: May We Send Here: Yes No EMERGENCY CONTACT Name: Relationship: Home Phone: ( ) Mobile Phone: ( ) EMPLOYMENT INFORMATION Employer: Length of Employment: Occupation: Average Hours Worked Per Week: EDUCATION INFORMATION Last Year of School Completed: GED College: Other: Are You Currently in School: Yes No. If Yes, What Level: Degree Pursuing: RELATIONAL INFORMATION Current Relational Status: Single Dating Engaged Married Separated Divorced Widowed
2 Are You Content with Your Current Relational Status: Yes No. If No, Briefly Explain: If Married, How Long: Number of Previous Marriages for You: For Your Partner: If Separated or Divorced, How Long: If Widowed, How Long: Partner s Name: Mr. Mrs. Ms. Miss How Long Have You Known Your Partner: Age: Partner s Race: White Black Hispanic Asian Other: Partner s Sex: Male Female Partner s Occupation: Average Hours Worked Per Week: Last Year of School Partner Completed: GED College: Other: What Words Would You Use to Describe Your Partner: Is Your Partner Supportive of You Seeking Counseling: Yes No Unsure Partner Doesn t Know With Whom Do You Currently Live (Check All that Apply): Alone Spouse Children Parent(s) Sibling(s) Boyfriend Girlfriend Roommate Other: CHILDREN Name Sex Age Relationship to You (natural, adopted) Living with You? Describe Him/Her Have You Ever Placed a Child for Adoption: Yes No. If Yes, When: Have You Ever Had a Miscarriage or Medical Abortion: Yes No. If Yes, When: Are There Any Custody/Visitation Issues: Yes No. If Yes, Elaborate: FAMILY OF ORIGIN List Mother, Father, Brothers, Sisters, Step Family, and Any Other Family Members who Effected You Positively or Negatively: Name Sex Age Relationship to You (e.g. mother, sister) Occupation Feelings About Relationship
3 MEDICAL INFORMATION Primary Physician: Phone: ( ) Address: City: Zip: Specialty (e.g. Family Practice, OB/GYN, Internal Medicine): Are You Currently Receiving Medical Treatment: Yes No. If Yes, Please Specify: List Any Conditions, Illnesses, Surgeries, Hospitalizations, Traumas or Related Treatments You Have Had (Use Back if Necessary): MEDICATIONS List All Current Medications You Are Taking, Including those You Seldom Use or Take Only as Needed (Use Back if Necessary): Medication: Dosage: Improves Prevents Controls: Medication: Dosage: Improves Prevents Controls: Are You Taking these Medication(s) According to Your Doctor s Recommendations: Yes No If No, Briefly Explain: PHYSIOLOGICAL SYMPTOMS Please Check Any of the Following Physiological Symptoms/Sensations that Apply to You Presently, or in the Recent Past: Headaches.... Past Present Dizziness... Past Present Stomach Trouble.. Past Present Visual Trouble. Past Present Sleep Trouble.... Past Present Trouble Relaxing.. Past Present Weakness. Past Present Tension. Past Present Rapid Heart Rate.. Past Present Difficulty Breathing. Past Present Intestinal Trouble.. Past Present Hearing Noises. Past Present Change in Appetite.. Past Present Tiredness... Past Present Pain Past Present Hearing Voices Past Present Seeing Things.... Past Present Other. Past Present Your Height: Your Weight: How has Your Weight Change in the Last 2-3 Months: CURRENT STATUS Please Check Any of the Following Problems which Pertain to You and/or Your Family: Stress Past Present Nervousness. Past Present Anxiety.. Past Present Panic. Past Present Unhappiness. Past Present Depression... Past Present Guilt.. Past Present Apathy... Past Present Terminal Illness... Past Present Recent Death. Past Present Grief.. Past Present Hopelessness.. Past Present Inferiority Feelings Past Present Defective Feelings. Past Present Loneliness.. Past Present Shyness.. Past Present Fears.. Past Present Friends... Past Present Marriage Past Present Communication. Past Present Physical Abuse... Past Present Emotional Abuse... Past Present Verbal Abuse. Past Present Sexual Abuse... Past Present Temper.. Past Present Anger. Past Present Aggressiveness... Past Present Bad Dreams... Past Present Concentration... Past Present Racing Thoughts. Past Present Unwanted Thoughts... Past Present Memory. Past Present Loss of Control Past Present Impulsive Behavior Past Present Self-Control... Past Present Compulsivity... Past Present Sexual Problems. Past Present Pregnancy.. Past Present Abortion... Past Present Legal Matters... Past Present Trauma... Past Present Eating Problems... Past Present Drug Use. Past Present Alcohol Use.... Past Present Trouble with Job.. Past Present
4 Career Choices Past Present Ambition Past Present Making Decisions Past Present Children... Past Present Being a Parent.... Past Present Finances.... Past Present Recent Loss. Past Present Disaster.. Past Present Other. Past Present Please Elaborate on Any of the Following Above: LEVEL OF DISTRESS Indicate How Distressed You Are by Placing an X on the Scale Below (1 = Very Little Distress; 10 = Extreme Distress): Are You Currently Experiencing Any Suicidal Thoughts: Yes No. Have You Experienced Them in the Past: Yes No Have You Ever Attempted Suicide: Yes No. If Yes, When and How: Have Any of Your Friends or Family Ever Committed or Attempted Suicide: Yes No If Yes, Who & When: CURRENT ISSUES AND GOALS Please Describe Why You Are Coming to Counseling (i.e. What Are Your Issues, Problems?): Why Have You Decided to Come for Counseling Now: What Do You Hope to Gain or Change by Coming for Counseling: How Long Do You Believe Counseling Should Last: PREVIOUS COUNSELING List Any Previous Counseling, Psychiatric Treatment, or Residential/In-Patient Care You Have Received (Use Back If Necessary): Therapist: Location: Dates: Reason: Therapist: Location: Dates: Reason: RELIGIOUS BACKGROUND What Words Would You Use to Describe Yourself: If God Were to Describe You, What Would He Say: Briefly Describe the Religious Environment of Your Home as You Were Growing Up: Complete the Following Thought: God Is Do You Regularly Attend a Place of Worship: Yes No. If Yes, Where: What Is the Name of Your Pastor, Priest, Rabbi, or Other Spiritual Leader: Do You Have a Personal Support System: Yes No. If Yes, Who: I have answered all questions to the best of my ability and attest the above information is true:
5 Signed: Date:
Journey to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA. 30062 (404 783-7086) NEW CLIENT INFORMATION Last Name of Client First Name Middle Initial Social Security
COUNSELING INTAKE FORM
COUNSELING INTAKE FORM Name Age Date Full Address Home Phone Work E-mail Work History Occupation How long? If presently unemployed, describe the situation Hobbies/Avocations Any past/present military service?
Life, Family and Relationship Questionnaire
Date of Initial Session: Client Name Date of Birth Address City Zip Phone Number Email Emergency Contact Relationship Emergency Contact Ph. # Client Name: Date: Life, Family and Relationship Questionnaire
ADULT HISTORY QUESTIONNAIRE
ADULT HISTORY QUESTIONNAIRE Date: Full Name: Date of Birth: If applicable, please complete the following: Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES
ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):
ADULT PATIENT HISTORY FORM DEMOGRAPHIC INFORMATION: Name: Address: City: State: Zip: Age: Date of Birth: Gender: Male Female Transgender Marital Status: Never Married Domestic Partners Married Separated
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
Choice Counseling Associates
Amy Vitacolonna, MS, LMHCA, RT/CT 719 Sleater-Kinney Rd SE, Suite 212 Lacey, WA 98503 (360) 349-8775 (office) (360) 584-9048 (fax) ChoiceCounselingAssociates@gmail.com ChoiceCounselingAssociates.com Choice
CERTIFICATION AND AUTHORIZATION (if applicable)
10301 Democracy Lane Suite 201 Fairfax, VA 22030 Phone: 703-547-3509 Fax: 703-383-3887 www.rrpsychgroup.com Date: PERSONAL DATA please mark with an asterisk (*) your preferred mode of contact Client Name:
Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx
Adult Information Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx 76092 817-614-1488 Dx code: Welcome to Restore Counseling Center. In order for us to gain a better understand of
Client Information Form
Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION Last Name: First: Middle:! Mr.! Mrs. Today s date: / /! Miss! Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
Christina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:
Office of: Sarah Horvath, LCSW Self-Report Form Page 1 Client s Name: Person completing report: Relation to Client: Street City State Zip Home Phone Work Phone Cell Phone Email: Date of Birth: Age: Gender:
A New Tomorrow Behavioral Health Services
A New Tomorrow Behavioral Health Services Tara L. Corbett MS, LPC Jenais Y. Means MA, LPC-I Linda L. Leech PhD, LPC, LPC-S Natasha Moseng MS, LPC-I 2635-A Hardee Cove, Sumter, S.C. 29150 Phone: (803) 883-4981
Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
JILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate
JILL L. KOFENDER, PHD, PLLC Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE Client s Name Today s Date Gender Age Birthdate Cell Phone Is it ok to text? Y N Is it ok to receive appt. reminders?
FMS Psychology, PLLC Adult Intake Form. Phone Number (Day): Phone Number (Evening):
FMS Psychology, PLLC Adult Intake Form General Information: Name: Date of Birth: / / Age: Gender: Address: Phone Number (Day): Phone Number (Evening): Primary Care Physician: Highest Level of Formal Education:
Name Last First Middle Date. Completed by: If not client, relationship to client. Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client Reason for Seeking Counseling: Personal Information Sex: [
ADULT INTAKE FORM. Name
Welcome to Solace Counseling Associates. Please note that the information is important for your care. Please fill out forms as completely as possible and have them ready before your first counseling session.
Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION. Client s Last Name First Name M.I. Street Address Date of Birth Age
Case #: Readmit? Yes No Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION PLEASE PRINT CLEARLY Today s Date: Client s Last Name First Name M.I. Street Address Date of Birth Age
SECTION 2: CURRENT CONCERNS Briefly describe the current concerns you would like to discuss with your counselor:
Page 1 Amarillo College Counseling Center Intake Packet The following information is needed to best serve you. Please clearly print your response to each question. SECTION I: IDENTIFYING INFORMATION Today
Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight
Client Information Name: Biographical Information Please complete this form, which will provide information useful in treatment. If you are not the patient (for example, if you are giving information about
Name Last First Middle Date. Completed by: If not client, relationship to client: Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client: Reason for Seeking Counseling: Sex: [ ] Male [ ] Female Place
Diana Valdez, PhD, LPC
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New Client Information. address: Date of Birth:
Milwaukee Area Psychological Services, S.C. (MAPS) 401 E. Kilbourn Avenue, Suite 402 Milwaukee, WI 52302 414-269-8660 (phone) 414-269-8656 (fax) New Client Information Your responses to the following questions
MINDFUL WELLNESS CENTER, PLLC
PATIENT HISTORY NAME DATE PLEASE TAKE YOUR TIME AND COMPLETE THE ENTIRE FORM. You may use the back if needed for more explanation. Identifying Information: Date of Birth: Age: Sex: Place of Birth: Religion:
Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
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ADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
Do not write below this line DSM IV Code: Primary Secondary. Clinical Information
New Client Registration Today s date Name Age Sex Address Social security # Date of birth Home phone May I call you at this number? y / n Leave a message? y / n Other numbers at which I can call you Can
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM
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SANDSTONE PSYCHOLOGICAL PRACTICE
SANDSTONE PSYCHOLOGICAL PRACTICE Christina L. Aranda, Ph.D. & Janell M. Mihelic, Ph.D. CONTACT INFORMATION New Client Questionnaire Name: Date: Date of Birth: Age: _ Address: Preferred Phone Number: Type:
C O U P L E S I N T A K E F O R M
COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
Address: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name:
Client Intake History
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Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
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PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNI
Date of Assessment ADULT PSYCHOSOCIAL HISTORY/INITIAL THERAPY INTAKE FORM Identifying Information: Name: Address: Age: D.O.B: Phone Number: Race: Gender: Religious Affiliation(optional): Current Household
Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
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Intake Questionnaire For New Adult Patients
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Application and History for Adult
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SLEEP QUESTIONNAIRE. BMI: (Risk if >30) Neck Circ: (Risk if: Male >16.5, Women >15)
SLEEP QUESTIONNAIRE Name: Date: Please place a check mark next to any of the following symptoms you are experiencing: Difficulty falling asleep and/or insomnia Excessive daytime sleepiness and/or fatigue
Demographic Information Form
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Last Name First Middle Date of Birth Age. Residence Address City State Zip Code
The following necessary information will help make your first session most productive. Please PRINT and fill out this form COMPLETELY. DEMOGRAPHICS Date: Last Name First Middle Date of Birth Age Residence
MERCY HOUSE RESIDENT APPLICATION FORM
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San Diego Center for the Treatment of Mood Disorders 1
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The Seed Planter Coaching & Counseling, PLLC Nanette Floyd Patterson, MA, LPC INTAKE FORM
Name Date Date of Birth Relationship Status Age Home Number # of Dependents Gender (Male/Female) Guardian s Name Telephone Mobile Phone Is it ok to leave a message at this number? (Yes/No) Work Phone Is
Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
Casey Alexander Paleos, MD NEW CLIENT INTAKE FORM 775 Park Avenue, Suite 200-2 Huntington, NY 11743 tel 631-629-5887 Date: / / BASIC INFORMATION Name: Gender: male female Age: Date of birth: / / Preferred
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
To be completed by Patient. Client Questionnaire
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Address: City/State/Zip: Home Phone: Cell: Pager: Work Phone: Employer/School: Emergency Contact: Phone:
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Atlanta Psychological Services
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CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:
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Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
Please fill out the entire form, answering the questions as they pertain to your child or teen. Leave blank any that are unclear or that you want additional clarification on. Thank you. General Information:
ADULT INFORMATION SHEET
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1 LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK 74074 405-707-9600 Date Personal History Information Client's Name Referred By Address Phone City/State/Zip Birthdate Age Occupation Employed by Social
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Child and Youth Background Information
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Minor Intake Form. Child s Name DOB
Page 1 of 5 Minor Intake Form Child s NameDOB Current Concerns: What concern brings you or your child in? When did this concern begin? (Please attempt to use dates.) Has your family/child been in therapy
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
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Henrike B. Kroemer, Ph.D. ADULT HISTORY FORM
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Please check all the behaviors and symptoms that you consider problematic:
Name Date Address Phone # Date of birth Email address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
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PHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
Client Name: Age: DOB: Date: What brings you to therapy?: How long has the problem been present?
Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LMFT, SEP, RN 600 West 78th Street, Suites 10A-C Mailing Address: PO Box 892 Chanhassen, MN 55317 Chanhassen, MN 55317 Phone: 952-215-5208
PHONE: RELATIONSHIP: ADDRESS:
Les Fehmi, Ph.D. 317 Mt. Lucas Road Princeton NJ 08540 609.924.0782 Fax: 609.924.0782 lesfehmi@openfocus.com www.openfocus.com Date: Interviewer: Referred By: 1. NAME: MALE/FEMALE BIRTH DATE: / / 2. ADDRESS:
Center for Transformative Counseling, Inc. 801 Georgia Street Key West, FL
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BACKGROUND HISTORY QUESTIONNAIRE
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Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
Intake Questionnaire
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Katarina R. Mansir, Psy.D. Licensed Psychologist PSY25417 (858) Name: Date: Presenting Concerns
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Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA 95688 Phone: (707) 624-9767 FAX: (707) 471-4140 Intake Paperwork for Adult Today s Date Referred By Please take time to
Steve Barns & Associates The Counseling Center of Denton Bible Church Christian Counseling Services Individual, Marriage, & Family
: Last First MI Male Female / / Age Email: @ Home: ( ) - Cell: ( ) - Address: Street (or P.O. Box) Apt. # City State Zip Code Emergency contact: ( ) - Place of Employment: How long? yrs. mos. Current Marital
Heartland Wellness Counseling Health Questionnaire
Heartland Wellness Counseling Health Questionnaire Today s Date: CLIENT INFORMATION Last name: First: Middle: Initial: Nick name: Marital status: Single Married Divorced Separated Widow Social Security
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York 10549 jablownp@optimum.net (914) 241-1246 Personal Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Address: City: State: Zip:
Deborah L. Galindo, Psy.D th St. SE, Ste 420 Salem, OR Phone: Fax: (503) or (503)
Deborah L. Galindo, Psy.D. 2601 25 th St. SE, Ste 420 Salem, OR 97302 Phone: 503-364-6093 Fax: (503) 566-9864 or (503) 364-5121 COUPLES THERAPY INTAKE QUESTIONNAIRE (EACH PARTNER NEEDS TO COMPLETE THIS
Note: If you have been a client here before, please fill in only the information that has changed.
Today s date: LMFT#100342 Note: If you have been a client here before, please fill in only the information that has changed. A. Identification Your name: Date of birth: Age: Nicknames or aliases: Home
Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
Adult Intake Form Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem: Check any of the following symptoms that you are experiencing: Distractibility
Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX History Form for Counseling Services
Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX 75230 214-280-3664 History Form for Counseling Services Client s Name: Age: Today s Date: / / Client s Sex: Client s Birthplace:
Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT
Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT DATE Name Date of Birth Age Class Year Email Cell Hometown/State Emergency Contact Emergency Number Gender Identity Race/Ethnicity
Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )
Adult Patient Information Name:, Sex:, Age: Ethnicity, Race Date of Birth:, Email address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( ) Cell: ( ) Referral by: Person to
Sonja Benson, Ph.D., PLLC Licensed Psychologist
Sonja Benson, Ph.D., PLLC Licensed Psychologist Date_ Referred by Name Date of Birth Social Security # Address_ City State Zip code Daytime Phone Nighttime Phone Cell Phone Email Male( ) Female ( ) Ethnicity
Dear Applicant: Complete ONLY the individual sections where there is a current or recent concern.
Dear Applicant: Thank you for your interest in becoming a patient at the Children s Psychiatric Services of South Texas (CPSOST). In order to provide you with the best care, it is important for our medical
problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the
Program Application. Name: SSN: Address: City: State: Zip: Phone: Date of Birth: Age: Occupation: Highest Grade Completed/College/Degree:
DATE: I. PERSONAL INFORMATION Name: SSN: Address: City: State: Zip: Phone: Date of Birth: Age: Occupation: Highest Grade Completed/College/Degree: Other skills/training: What tools can you use: Farm or
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital