Background Information Form

Background Information Form
Name*

First NameLast Name
Birthday*

MonthDayYear
Marital Status
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Education (in years) Number of Years Degree Degree
Parent's Name (if minor)

First NameLast Name
Occupation Occupation
Current Position Position How long Years in Position
Employed by Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Telephone
Please enter a valid phone number.
Work Fax #
Please enter a valid phone number.
IN CASE OF EMERGENCY NOTIFY:
Name

First NameLast Name
Relationship Emergency Contact Relationship
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone
Please enter a valid phone number.
Your cooperation in completing this form will be helpful in planning your services for you. Please answer each item carefully and completely. All information on this form is confidential and will not be released without your prior written approval.
BRIEFLY DESCRIBE YOUR REASONS FOR SEEKING HELP*
HAVE YOU EVER SEEN A PSYCHOTHERAPIST OR COUNSELOR OF ANY TYPE BEFORE? What were the reasons and outcome?*
DESCRIBE ANY MAJOR CHANGES IN YOUR LIFE IN THE PAST TWO YEARS*

List ALL medications you are now taking -- prescription (including birth control pills) and non-prescription (such as aspirin, allergy medication, etc...)

	MEDICATION	DOSAGES (amount & times per day)	REASON

Physician Physician Telephone Area Code Phone Number
Alcohol Intake: (Please describe average intake)

List the people currently living in your home

	Name	Age	Relationship	Occupation

It is a customary courtesy of our office to send a thank you note to the doctor or person who referred you for this consultation. Please indicate whether or not that is acceptable and, if it is, to whom the letter should be sent.*

You have my permission to send a letter of thanksPlease do not send a take you note
Please Initial*

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Referral Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Phone #
Please enter a valid phone number.
Is it OK to send mail to your home address?*

YesNo
Thank you for providing this information. Full payment is expected at the time services are rendered unless other arrangements are made. If cancellation is not made 24 hours in advance, you may be charged full sessions fees.
I HEREBY GUARANTEE PAYMENT FOR THE SERVICES TO THE CENTER FOR COGNITIVE THERAPY

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Date

MonthDayYear
Date
I HAVE BEEN GIVEN A COPY OF THE CALIFORNIA NOTICE FORM REGARDING PRIVACY
Signature

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Date

MonthDayYear
Date
Should be Empty:

Background Information Form

IN CASE OF EMERGENCY NOTIFY: