Catherine Selth Spayd, Ph.D., P.C.

Licensed Psychologist

Background Information Form

Please print out this form, complete it, 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 to therapy:_____________________________________________

___________________________________________________________________________

___________________________________________________________________________

_______

What are your main goals for therapy? ____________________________________________________________________________

____________________________________________________________________________

_______________________________________________

Mental Health Treatment History

(Approximate)Dates of Treatment:________________________________

Name of Therapist/Hospital :________________________________

Therapist's Training? (e.g.. Psychologist,Psychiatrist, other):__________________________

Psychiatric Medications Used (Specify) :___________________________________

Medical History

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

Current Medical Problems: ________________________________________________________________________

_____________________________________________________________

All Current Medications

Name:_______________________________
Dosage:_________________________
(Approximate) Date Prescribed:______________________
Purpose:___________________________
Prescribing Physician:_______________________

Name:_______________________________
Dosage:_________________________
(Approximate) Date Prescribed:______________________
Purpose:___________________________
Prescribing Physician:_______________________

Name:_______________________________
Dosage:_________________________
(Approximate) Date Prescribed:______________________
Purpose:___________________________
Prescribing Physician:_______________________

Any previous/current criminal charges:___________________________________________________________________

__________________________________________________________________________

___________________________________________________________________________

________________________________________

Family History

Marital Status(check): _____ Single ___ Married ___ Separated ___ Divorced ___ Widowed_____
Number of Previous Marriages:_____

Spouse

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Children

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Mother

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Father

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Siblings

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________

Name:_______________________
Age:________
Occupation:__________________
Deceased?:__________
Where does s/he live:__________________


Where are you in the birth order? ___of ___children.

Were you adopted?(circle one): Yes/No

Anyone else living in your house at this time:_________________ Relationship_________________

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