DIRECTIONS
Please print out and complete this confidential information sheet.  Print the information clearly.  When you are finished, bring it with you to the first appointment.  Also, please go to the Office Police and Procedure page, read it, then print out two copies, sign one and keep one.  Bring that with you also.  For couples, both need to fill out the form.

PERSONAL INFORMATION

Today's Date:

Name:                                                                                                            Gender:   M      F

Address:

City:                                                                                                    ZIP:

Telephone Numbers:   Work:                                                       Home:

E-Mail Address:

Date of Birth:                                                  Age:                  Place of Birth:

Religion:                                                        Congregation:

Last Grade Completed/Highest Degree Earned:

Occupation:                                                      Employer:

In case of emergency, notify:                                                               at:

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It is my policy to never release any inform regarding a client unless I have written permission to do so.  On occasion I must contact you by telephone regarding an appointment change.  May I identify myself when leaving a message at your home?
At work?
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FAMILY BACKGROUND

Father's Name                                                       Age                   Deceased (Date)

Mother's Name                                                      Age                   Deceased (Date)

Brothers/Sisters                                                    Age                   Deceased (Date)








MARITAL INFORMATION

Name of Spouse:                                                             How long have you been married?

Are you:   Divorced                   Widowed            Separated         Living with Partner
                  Never Married

If you've been married before, please give name of former spouse(s) and dates of those marriages




Name and ages of children in order of birth

Name                                              Age            Gender                  Adopted/Step Child














MEDICAL INFORMATION

Name of Primary Care Physician:

Medications (Name and Reason):





Previous Therapy (Therapist's name and Reason):



Are you presently seeing another therapist?                       Name:

Have you had any psychiatric hospitalizations?              

If yes, please state where, when and for what reason:



Your reason for coming now:



GUARANTOR OF PAYMENT

Social Security Number:

Person Responsible for Payment:

If other than self, provide name, address and telephone number of responsible party:



Do you plan to file claims for service with your insurance company?

If yes, name of insurance company:

REFERRAL SOURCE

How did you find out about my services?