Document Center

Date of Initial Visit

MM

DD

YYYY

Patient Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insured's Date of Birth

MM

DD

YYYY

Are you currently working with another therapist?

Yes No

Option One

Option Two

Do you use any of the following:

Check all that apply

Alcohol

Recreational Drugs

Tobacco

Caffeine

Please complete the survey below

I exercise frequently

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I describe myself as spiritual or religious

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I have experienced physical or sexual abuse as a child or adult

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Would custodial parent need to be notified if non-custodial parent requests copy of child’s records?

Yes

No

N/A