Background Information Form
Home
Contact Us
Our Location
Professional Services
Older Adults
Adult ADHD
Forms for New Patients
Scheduling & Keeping Appointments

Background Information Form

Please print out and complete this form and bring it with you to your first session.  If you find any of the questions difficult to answer or offensive in any way, just leave them blank. Please use the back of the form if more space is needed.

 

Name:_____________________________                Date Completed:_________________

 

Emergency Contact Name:___________________     Relationship: ____________________

Emergency Contact Phone #:___________________

 

Occupation:____________________             Years of Education:____________________

 

Ethnic Background:______________            Religion:_____________________________

 

Concerns that bring you for evaluation or treatment:____________________________________________________________________________________________________________________________

 

What are your main goals for evaluation or treatment?_____________________________________________________________________________________________________________________________________

 

Mental Health Evaluation/Treatment History

 

                             Name of            Provider’s        Psychiatric      Inpatient (I)

(Approximate)     MH Provider/      Training?         Meds. Used?   Outpt. (O)

Dates of service      Hospital       e.g. Psychologist,    (Specify)             

                                                 Psychiatrist, other)  

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

 

Medical History

 

Primary Care Physician (PCP):____________________ PCP Phone #______________

PCP Address:____________________________________________________________

 

Current Medical Problems:  _____________________________________________________________________________________________________________________________________

 

Serious Past Medical Problems:

 

______________________________________________________________________________________________________________________________________

All Current Medications

                                   (Approximate) Date                                Prescribing

Name         Dosage         Prescribed                   Purpose            Physician

________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Any previous/current criminal charges:__________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 

Family History

 

Marital Status: __Single___ Married __Separated  __ Divorced __Widowed

Number of Previous Marriages:_____

 

              Name       Age      Occupation     Deceased?   Where does s/he live?

 

Spouse    ______________________________________________________________

 

Children   ______________________________________________________________

            _______________________________________________________________            _______________________________________________________________            _______________________________________________________________

Mother    ______________________________________________________________

 

Father     ______________________________________________________________

 

Siblings   ______________________________________________________________                _______________________________________________________________            _______________________________________________________________            _______________________________________________________________

 

Name of Power of Attorney for Estate (finances)______________________

 

Name of Power of Attorney for Person (medical, personal affairs) _________

 

Where are you in  birth order? ___of ___children. Were you adopted? Y/N

Anyone else living in your house at this time:_________ Relationship_______

 

 Catherine S.  Spayd, Ph.D., P.C.

Duncansville Professional Center

841 Third Avenue

Duncansville, PA     16635

 

Phone (814) 693-0617                                                                                      www.DrSpayd.com

Fax (814) 317-0348           

                                                                                               

Please bring back this page to your first session, for inclusion in your clinical record

 

Your signature here allows the office to bill your insurance company and receive direct compensation for psychological services provided by Catherine S. Spayd, Ph.D.

 

X_________________________________________                     _________________________

Patient Signature                                                                                                     Date

 

Attached is the 1. Notice of Mutual Responsibility for Scheduling Appointments . Below is the

2. Request for Alternative Confidential Handling of Health Information.   By HIPAA regulations, you also have the right to read and receive copies of the following Documents, which will be offered to you at your first session: 3. Psychotherapist Patient Services Agreement, and 4. Pennsylvania Notice Form.   

 

Your signature below indicates that you have been given the opportunity to read the information in the four documents listed above, and you agree to abide by their terms during our professional relationship.  Further, you understand that if you leave blank the two narrative sections of the Request for Alternative Handling of Confidential Health Information (below), the standard office procedures described in the Agreement will be followed. It also allows the office to bill your insurance company and receive direct compensation for psychological services provided by Catherine S. Spayd, Ph.D.

 

                               Request for Alternative Confidential Handling of Health Information

 

I request that Catherine S. Spayd, Ph.D., and her staff telephone me in the following, alternative manner (please leave numbers and any specific instructions regarding the leaving of messages):

 

 

 

 

I request that Catherine S. Spayd, Ph.D., and her staff send me mail in the following, alternative manner (please leave address(es) and any specific instructions be followed to receive mail sent to you from our office:

 

 

 

 

 X _________________________________________                     _________________________

Patient Signature                                                                                                     Date