Background Information Form

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