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Patient Record
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* Indicates required question
Email
*
Your email
Patient:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
*Current Age
*If under 18-yrs-old, parental consent needed
Your answer
Address:
Your answer
City:
Your answer
State:
Your answer
Zip:
Your answer
Cell Phone:
Your answer
Home Telephone:
Your answer
Work Telephone:
Your answer
Sex:
Female
Male
Clear selection
Subscriber S.S.#:
Your answer
Employer/School:
Your answer
Job Title/Grade:
Your answer
Marital Status:
Married
Single
Divorced
Widowed
Clear selection
Partner’s Name:
Your answer
Emergency Contact:
Your answer
Telephone:
Your answer
Guardianship Information (if relevant):
Name:
Your answer
Address:
Your answer
Contact Number:
Your answer
Relevant medical conditions (history, current condition, changes in condition):
Your answer
Medications (dosage, dates of initial prescriptions, name of prescribing professional):
Your answer
Allergies/adverse reactions to treatment:
Your answer
Primary Care Physician Name:
Your answer
Telephone:
Your answer
Address:
Your answer
City:
Your answer
Zip:
Your answer
Date of last medical/physical exam:
MM
/
DD
/
YYYY
Reason for seeking therapy:
Your answer
Treatment Goals:
Your answer
Past psychological or psychiatric treatment:
Your answer
Psychiatric hospitalizations (Dates and Locations):
Your answer
Family History of psychological or psychiatric treatment
Your answer
Do you drink coffee?
Yes
No
Clear selection
# cups/daily
Your answer
Do you smoke Cigarettes?
Yes
No
Clear selection
# per day
Your answer
Alcohol?
Yes
No
Clear selection
# drinks weekly
Your answer
Date last drank:
MM
/
DD
/
YYYY
Family History of Alcoholism?
Yes
No
Clear selection
Marijuana use (past or present)
Yes
No
Clear selection
Date last used:
MM
/
DD
/
YYYY
Other street drug use (past of present)
Yes
No
Clear selection
Street drugs:
Type:
Your answer
Amount:
Your answer
Frequency:
Your answer
Date last used:
MM
/
DD
/
YYYY
Police / Probation involvement (past or present)
Yes
No
Clear selection
Date:
MM
/
DD
/
YYYY
Please explain:
Your answer
Family Structure (who lives in your household? Please provide names, ages and relationship to each):
Your answer
Please check if you have experienced any of the following (past or present):
Domestic Violence
Traumas
Sexual Abuse
Physical Abuse
Sleep Problems
Eating Disorders
Losses
Learning Problems
Suicide Attempts
Suicidal Ideation
Auditory Hallucinations
Visual Hallucinations
Spending Sprees
Outbursts of Anger
Lying
Phobias
Mood Changes
Worry/Fear
Panic Attacks
Poor Concentration
Tearfulness
Fatigue
Feeling Hopeless/Helpless
Head Injury or Seizures
Religious preference
Your answer
What are your strengths
Your answer
What are your weaknesses
Your answer
Motivation for treatment
Your answer
Any other information you believe may be significant
Your answer
Signature
*
Type your name here for your consent to use this information
Your answer
Patient Record Date:
MM
/
DD
/
YYYY
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