Name: _________________________________________ Age: ______ Birthdate: ____________ Today's Date: ________

Address: ____________________________________________________________ Home phone: __________________

Street or P.O. Box number

City

State

Zip code

Electronic mail address ________________________________________________ Office or work phone: _____________

Birthplace: __________________ Marital status: ______ # times married: _______ # years in current marriage: __________

Occupation: _________________ Employer: ______________________________ Education: ______________________

Spouse's name: ______________ Employer: ______________________________ Occupation: _____________________

Religion: ___________________ Who referred you? _______________________ Family doctor: ____________________

List any major health problems: ________________________________________________________________________

Please list any medications you take: ____________________________________________________________________

Have you been in therapy before? _______ If yes, when? _____________ Problem? _______________________________

Whom did you see? ________________________________ Did it help?

yes

some

no

How many children do you have? ______ Please list first names and ages: ________________________________________

(please circle the names of those currently living with you)

_________________________________________________________________________________________________

Please check or circle any of the following that are currently troubling you:

inferiority feelings nervousness suicidal thoughts making decisions health problems stomach trouble career choices concentration being a parent marriage

children shyness separation drug use/abuse anger sleep relaxation painful thoughts energy legal matters

loneliness education guilt bowel trouble depression divorce alcohol use compulsions self-control ambition

headaches insomnia agoraphobia appetite fears finances friends confidence unhappiness stress

phobias extreme fatigue panic attacks overweight sexual abuse abused as a child battered/beaten temper ACOA work

tiredness sadness sexual problems fetishes conflict self-esteem homicidal no interests impotence legal problems

_________________________________________________________________________________________________

Please describe briefly your reasons for seeking psychological consultation or therapy:




What do you hope to get out of this consultation?

_________________________________________________________________________________________________

Signature (in case I get a release form requesting copies or records or other information about you --
I want to be able to make sure it's actually
YOUR signature: _________________________________ SSN: _______________________________

Please be aware that we operate on a "cash" basis. That is, we expect FULL payment at the time of each visit. If you have health insurance that covers psychological
services my part time office manager (Ruth Register) can file your insurance claims for you, if you like. We currently charge $110.00 per 45-50 minute "hour." I generally
operate very much on time so it will be to your advantage to arrive on time for your appointment. Your appointment time is reserved exclusively for you, and thus we
do charge for uncancelled or missed appointments. If you have questions about financial arrangements please bring them up. Thanks!
Revised September 25, 2004