Patient Record
Email address *
Patient:
Date of Birth:
MM
/
DD
/
YYYY
*Current Age
*If under 18-yrs-old, parental consent needed
Address:
City:
State:
Zip:
Cell Phone:
Home Telephone:
Work Telephone:
Sex:
Clear selection
Subscriber S.S.#:
Employer/School:
Job Title/Grade:
Marital Status:
Clear selection
Partner’s Name:
Emergency Contact:
Telephone:
Guardianship Information (if relevant):
Name:
Address:
Contact Number:
Relevant medical conditions (history, current condition, changes in condition):
Medications (dosage, dates of initial prescriptions, name of prescribing professional):
Allergies/adverse reactions to treatment:
Primary Care Physician Name:
Telephone:
Address:
City:
Zip:
Date of last medical/physical exam:
MM
/
DD
/
YYYY
Reason for seeking therapy:
Treatment Goals:
Past psychological or psychiatric treatment:
Psychiatric hospitalizations (Dates and Locations):
Family History of psychological or psychiatric treatment
Do you drink coffee?
Clear selection
# cups/daily
Do you smoke Cigarettes?
Clear selection
# per day
Alcohol?
Clear selection
# drinks weekly
Date last drank:
MM
/
DD
/
YYYY
Family History of Alcoholism?
Clear selection
Marijuana use (past or present)
Clear selection
Date last used:
MM
/
DD
/
YYYY
Other street drug use (past of present)
Clear selection
Street drugs:
Type:
Amount:
Frequency:
Date last used:
MM
/
DD
/
YYYY
Police / Probation involvement (past or present)
Clear selection
Date:
MM
/
DD
/
YYYY
Please explain:
Family Structure (who lives in your household? Please provide names, ages and relationship to each):
Please check if you have experienced any of the following (past or present):
Religious preference
What are your strengths
What are your weaknesses
Motivation for treatment
Any other information you believe may be significant
Signature *
Type your name here for your consent to use this information
Patient Record Date:
MM
/
DD
/
YYYY
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