SECTION A (Everyone completes)
First Name Middle init. Last Name
Prefer to be called
Today’s date: Birth date: Age

Current marital status: Spouse’s or ex-spouse’s name:

Check all that apply: Evaluation for Psychotherapy, individual Psychotherapy, marriage
Psychotherapy, couple’s Psychotherapy, family/parent Psychological testing
Psycho-educational testing ADHD testing Other:

Employed full time Employed part-time Student, ft Student, pt Unemployed or Retired

Referred by: Your Physician:

School contact:
Other health care (psychiatrist, psychotherapist, ADHD coach, etc.):

Home phone: Work phone: Cell phone:

E-mail:

Street Address:
City: State: Zip:
Who else can attend your sessions or take messages, if any, and their relation?

Do you have any disabilities under ADA? Yes No
Are you involved in or do you anticipate ANY legal litigation? Yes No

List any medications or medical conditions affecting psychological functioning:
Who should be contacted in a medical or psychiatric emergency?

SECTION B (Complete only for minor patients)
Father: Custody status: Mother: Custody status:
Father’s phone: Mother’s phone:
Stepfather: Phone: Stepmother: Phone:
If patient is a child of divorced parents, what is custody arrangement?
Who is responsible for authorization and payment of medical and psychological services?

School and grade:
School contact person (optional):
Pediatrician:
List any educational special classifications, eligibility, accommodations, or interventions:
Siblings’ names and ages: