Confidentiality Statement:
Case records are strictly confidential. No outsider, not even your closest relative or family doctor is permitted to see your case record without your written permission or court order.
Family History:
Medical History:
Drug/Medication History:
Because many drugs (legal and illegal) have psychological effects, it is important for me to know what drugs you are currently taking and/or have taken in the past. This information will remain strictly confidential. It is very important for me to know before you begin therapy so that an accurate assessment of your situation can be made.
Symptoms:
Please provide three people who may be notified in case of emergency: