Confidential Patient Information Confidential Patient Information Name * Address * Address Street Street Apartment #, Unit, Suite, etc. Apartment #, Unit, Suite, etc. City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Telephone * Home Phone Work Phone Cell phone Date of Birth * Driver's Lic # * Employer Employer's Address Emergency Contact (Name, Address, Phone) * Do you use alcohol or drugs? * Yes No If yes, then how often? Do you have a history of childhood abuse? * Yes No If yes, was the abuse sexual, emotional, physical, verbal or more than one? Do you have a history of depression? * Yes No If yes, when? Do you have a history of anxiety? * Yes No If yes, when? Have you ever been diagnosed with an emotional or mental condition? * Yes No If yes, please describe. Are you currently on any medications for an emotional or mental condition? * Yes No If yes, please list. Do you have legal problems? * Yes No If yes, please describe. Does anyone in your family of origin have a mental disorder, drug/alcohol problems, or any other psychological problems? * Yes No If yes, please describe. Are you married? * Yes No Were you previously married? * Yes No Do you have any children? * Yes No If yes, please list names of children, ages and gender. Any history of domestic violence? * Yes No If yes, describe when and with whom. Please describe any other family concerns. Please describe or list any other concerns you have (relationship, work, health, mental....) How did you hear about me and my services? * Referred by a past patient Referred by another therapist or medical doctor (list name of clinician below)Referred by another therapist or medical doctor (list name of clinician below) Found on the internet (list name of search engine and /or website)Found on the internet (list name of search engine and /or website) Found on Psychology Today Referred by (click to provide specific name)Referred by (click to provide specific name) Signature * Date * Submit