NAME_______________________________________________ DATE ___________

ADDRESS _____________________________________________________________

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AGE ____ DATE OF BIRTH ____________ SEX____ MARITAL STATUS_________

PHONE HOME ________________ WORK _______________CELL______________

SOC. SEC. # ________________________ EDUCATION _______________________

OCCUPATION ________________________ EMPLOYER ______________________

PERSONAL PHYSICIAN _________________________________________________

MAJOR HEALTH PROBLEMS _____________________________________________

CURRENT MEDICATIONS _______________________________________________

IN CASE OF EMERGENCY, NOTIFY_______________________________________ 

TELEPHONE___________________________________________________________

REFERRAL SOURCE ____________________________________________________

BRIEFLY DESCRIBE YOUR REASONS FOR SEEKING SERVICES ______________________________________________________________________

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DATES AND REASONS FOR PREVIOUS MENTAL HEALTH TREATMENT _______________________________________________________________________

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Carol Twitchell PsyD
Clinical Psychologist

I acknowledge receipt of the Psychotherapist-Client Services Agreement and agree to abide by its terms.

Client’s Signature _________________________________________ Date ___________

I acknowledge receipt of the Notice of My Policies and Practices to Protect the Privacy of Your Health Information.

Client's Signature_________________________________________ Date ____________

Signatures below only for those using insurance:

I authorize the release of any medical or other information necessary to process my insurance claim.

I know that I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.

Client’s Signature _________________________________________ Date ___________

I authorize payment of medical benefits to Carol Twitchell, Psy.D. for services rendered.

Client’s Signature _________________________________________ Date ___________