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Your Information
Appointment booking
Date
First name
*
Last name
Date of birth
*
Gender
*
Male
Female
Other
Marital Status(if applicable)
*
S
M
D
W
Address
*
Apt#
City
State
Zip
Email address
*
Contact Tel
*
Work Tel
Home Tel
Occupation/School
Employer/College
Emergency Contact Info
Name
*
Relationship
Address
*
Phone
*
For MINORS only
No
Yes
Parent/Guardian-1
First Name
*
Last name
Date of birth
*
Marital Status
S
M
D
W
Address
*
City
State
Zip
Email address
*
Contact Tel
*
Work Tel
Home Tel
Occupation/School
Employer/College
Parent/Guardian-2
First name
Last name
Date of birth
Marital Status
S
M
D
W
Address
City
State
Zip
Email address
*
Contact Tel
*
Work Tel
Home Tel
Occupation/School
Employer/College
INSURANCE COVERAGE
What Insurance Carrier do you have?
Aetna
Cigna
United Healthcare
Self Pay
Insurance ID Number
*
Policy Holder’s Name
*
Policy Holder’s DOB
*
How did you hear about OUR services?
Psychology Today
Yelp
Google Search
Facebook
Healthgrades
Park Slope Parents
Insurance company website
Other
How did you hear about OUR services?
What is your reason for making an appointment?
*
PRIMARY CARE PROVIDER
check if none
Name
Phone
Date of last visit
Frequency of visits
PSYCHOLOGIST OR THERAPIST
check if none
Name
Phone
Date of last visit
Frequency of visits
CURRENT/FORMER PSYCHIATRIST
check if none
Name
Phone
Date of last visit
Frequency of visits
MEDICAL CONDITIONS (please list all medical conditions that you have been evaluated for,diagnosed with, and/or treated for, both current and past)
SPECIALISTS SEEN (at any point in the past)
CURRENT MEDICATIONS : including OTC (over-the-counter) drugs, herbal remedies, and nutritional supplements, both daily and occasional use
PAST MEDICATIONS
FAMILY HISTORY
ALLERGIES (to medications or foods)
*
HOSPITALIZATIONS, SURGERIES, & EMERGENCY ROOM VISITS
Have you ever had
seizures
blackouts
fainting spells
heart palpitations
chest pain
shortness of breath/asthma
fracture or severe injury a head injury/concussion
NONE OF THE ABOVE
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Appointment booking therapists
Date
First name
*
Last name
Date of birth
*
Gender
*
Male
Female
Other
Address
*
Apt#
City
State
Zip
Email address
*
Contact Tel
*
Work Tel
Home Tel
Occupation/School
Employer/College
Please list your referral source
Who do you live with?
Emergency Contact Info
Name
*
Relationship
Address
*
Apt #
City
State
Zip
Cell Phone Number
*
Work Phone Number
For MINORS only
No
Yes
Parent/Guardian-1
First Name
Last name
Date of birth
Marital Status
S
M
D
W
Address
City
State
Zip
Email address
Contact Tel
Work Tel
Home Tel
Occupation/School
Employer/College
What brings you to therapy?
Which of the following are you currently experiencing? Check all that apply and indicate severity from 1 (lowest)-10 (highest)
Depression
*
1
2
3
4
5
6
7
8
9
10
Anxiety
*
1
2
3
4
5
6
7
8
9
10
Mood Swings
*
1
2
3
4
5
6
7
8
9
10
Changes in Appetite
*
1
2
3
4
5
6
7
8
9
10
Changes in Sleep
*
1
2
3
4
5
6
7
8
9
10
Panic Attacks
*
1
2
3
4
5
6
7
8
9
10
Excessive Worry
*
1
2
3
4
5
6
7
8
9
10
Irritability
*
1
2
3
4
5
6
7
8
9
10
Low Energy
*
1
2
3
4
5
6
7
8
9
10
Difficulty Concentrating
*
1
2
3
4
5
6
7
8
9
10
Confusion
*
1
2
3
4
5
6
7
8
9
10
Racing Thoughts
*
1
2
3
4
5
6
7
8
9
10
Loss of Interest in Activities/Hobbies
*
1
2
3
4
5
6
7
8
9
10
Issues at Work
*
1
2
3
4
5
6
7
8
9
10
Marital/Relationship Stress
*
1
2
3
4
5
6
7
8
9
10
Suicidal Thoughts
*
1
2
3
4
5
6
7
8
9
10
Changes in Sexual Interest
*
1
2
3
4
5
6
7
8
9
10
Obsessive Thoughts or Behaviors
*
1
2
3
4
5
6
7
8
9
10
Self Harming
*
1
2
3
4
5
6
7
8
9
10
Hyperactivity
*
1
2
3
4
5
6
7
8
9
10
Hallucinations
*
1
2
3
4
5
6
7
8
9
10
Hopelessness
*
1
2
3
4
5
6
7
8
9
10
Bullying
*
1
2
3
4
5
6
7
8
9
10
Isolation
*
1
2
3
4
5
6
7
8
9
10
Frequent Crying
*
1
2
3
4
5
6
7
8
9
10
Increased Substance Use
*
1
2
3
4
5
6
7
8
9
10
Binging / Purging
*
1
2
3
4
5
6
7
8
9
10
How long have these been present in your life?
What are you looking to gain from therapy?
Medical History and Mental Health Background
Have you ever seen a therapist before?
No
Yes
If so, how long ago?
How long were you working with this therapist?
What was your experience like?
Have you ever had a mental health hospitalization or have been in intensive outpatient treatment?
No
Yes
If so, how long ago?
Which hospital or program?
What was your experience like?
Have you ever been treated with medication for a mental health problem?
No
Yes
Are you currently still on this medication?
No
Yes
If so, please list names of medication, reason prescribed, and reaction/experience with it.
Do you have a primary care provider?
No
Yes
Name
Phone
Date of last visit
Frequency of visits
This information is for our records only and any communication with the above named providers will only occur with your signed authorization
Please list all medical conditions that you have been evaluated for,diagnosed with, and/or treated for, both current and past
Please list any allergies
Do you have any chronic pain or medical issues you wish to share?
Family History
A) Please list the names and ages of your parents and siblings, including step siblings, half-siblings, or any other immediate family members that you are close with.
B) Please indicate any mental health or medical issues that you are aware of in your family history, including parents, siblings, grandparents, aunts, uncles, cousins, etc.
C) Has anyone in your family seeked mental health treatment, including therapy, hospitalizations, rehabs, 12 step fellowships, etc.?
Social and Marital History
A) Please indicate your sexual orientation
B) Are you looking to explore this area of your life? If so, please explain
c) Relationship Status
In a relationship
Casually dating
n a Polyamorous Relationship
Single
Married
Divorced
Living with Partner
Widowed
Please indicate how long you have been in your relationship, been married, been divorced, lived with your partner, or been widowed, if applicable
Have you ever been or are you currently in a relationship that you feel was/is verbally, emotionally, physically, or sexually abusive?
D) Are you struggling with issues surrounding your gender identity? If so, please explain
E) Please describe your current living situation, including who you live with and for how long
Substance Abuse History
Substance Abuse History
Please indicate which of these substances you use, if any, including frequency, duration, and history of
use
Alcohol
Marijuana
Tobacco (including vaping)
Cocaine
Molly/Ecstasy
Heroin
Crack Cocaine
Other
Are you experiencing any distress related to your use? This could include interpersonal/relationship issues, problems at work or school, financial, etc.
Legal History
Do you have any legal involvements, either currently or in the past? If so, please explain.
Finally, is there anything else you would like me to know?
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Payment Information
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CARD NUMBER
EXPIRY DATE
CVC CODE
Booking now
Your card will be charged at the time of the appointment booking.
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