(Individuals fill out "patient" only, couples fill out both "patient" and "partner" sections)

Name:    Sex:M F    DOB (MM/DD/YYYY): 

Spouse/Partner:    Sex:M F    DOB (MM/DD/YYYY): 

Patient Home #:    Work #:    Cell #: 

Spouse/Partner Home #:    Work #:    Cell #: 

Patient Address:    City:     State:    Zip: 

Spouse/Partner Address: Same As Above

   City:    State:    Zip: 

Referred by (if via Internet, please specify site): 

Patient Email: 

Spouse/Partner Email: 

Presenting Problem: 

Medications (patient): 

Medications (spouse/partner): 

Medical Problems (patient): 

Medical Problems (spouse/partner): 

Previous Psychotherapy (patient): 

Previous Psychotherapy (spouse/partner): 

Drug/Alcohol Use (patient): 

Drug/Alcohol Use (spouse/partner):