Biographical-Data-Intake-Form-revised

Dr. Debra Mandel-A Professional Psychological Corporation Service Provider:
Debra Mandel, Ph.D.
License #PSY11225 818.335.6309
drdebra@dmdoc.com www.drdebraonline.com

Biographical Information – Intake Form
Name*

First NameLast Name
Gender
DATE*

MonthDayYear
Date
DATE OF BIRTH

MonthDayYear
Date
PLACE OF BIRTH
Age
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Mobile Phone Number
Work/Office Phone Number
Fax Phone Number
FOR ROUTINE MESSAGES:
Phone Number*
Email Address*
FOR CONFIDENTIAL/PRIVATE MESSAGES:
Phone Number
Email
Text
Education
HIGHEST GRADE/DEGREE
TYPE OF DEGREE
Emergency Contact
Name
Phone
REFERRAL SOURCE
OCCUPATION (former, if retired)
PRESENTING PROBLEM (be as specific as you can: when did it start, how does it affect you.)
Estimate the severity of above problem

MildModerateSevereVery Severe
CURRENT RELATIONSHIP STATUS:
Marital Status
Live with Someone
Name
Years
PAST & PRESENT MARRIAGE/S (names, years together, and statement about the nature of the relationship(s), i.e., friendly, distant, physically/emotionally abusive, loving, hostile.)
PRESENT SPOUSE/PARTNER
Name
Education
Occupation
Family Relationships
CHILDREN/STEP/GRAND (names/ages & brief statement on your relationship with the person
1.
2.
3.
PARENTS/STEPPARENTS (Name/age or year of death/cause of death, occupation, personality, how did s/he treat you, brief statement about the relationship:
Father
Mother
Stepparents
SIBLINGS (name/age, if deceased: age and cause of death and brief statement about the relationship:
1.
2.
3.
MEDICAL DOCTOR(s)
List Names and Phone Numbers of your medical doctors
PAST/PRESENT MEDICAL CARE (major medical problems, surgeries, accidents, falls, illness, etc.)
SPECIFY MEDICATION you are presently taking and for what.
PAST/PRESENT DRUG/ALCOHOL USE/ABUSE (AA, NA, treatments)
SUICIDE ATTEMPT/S or VIOLENT BEHAVIOR (describe: ages, reasons, circumstances, how, etc.)
FAMILY MEDICAL HISTORY (Describe any illness that runs in the family: e.g., cancer, epilepsy, etc.)
FRIENDSHIPS, COMMUNITY, & SPIRITUALITY
PAST/PRESENT PSYCHOTHERAPY
Please specify: month year(s) (beginning—end), estimated no. of sessions, name, degree, phone & address, initial reason for therapy, Individual/Couple/Family, medication, brief description of the relationship and how helpful it was, and how/why it ended
1.
2.
3.
More.....
DESCRIBE YOUR CHILDHOOD, IN GENERAL (Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems, abusive/alcoholic parent)
IF PARENTS DIVORCED: Your age at the time
Describe how it affected you at the time
Social Media
ESTIMATE HOW MANY HOURS/DAY YOU SPEND ONLINE (Facebook, YouTube, internet gaming, texting, browsing, etc.
Facebook
YouTube
Gaming
Texting
Browsing
Work/School
Other
DO YOU FEEL YOUR TECHNOLOGY USE IS BALANCED AND HEALTHY OR COULD IT USE IMPROVEMENT? Please explain
FAMILY HISTORY OF ALCOHOLISM, MENTAL ILLNESS, OR VIOLENCE (Including suicide, depression, hospitalizations in mental institutions, abuse, etc.)
ARE YOU INVOLVED IN ANY CURRENT OR PENDING CIVIL OR CRIMINAL LITIGATION/S, LAWSUIT/S OR DIVORCE OR CUSTODY DISPUTE/S? (if you answer Yes, please explain)
What gives you the most joy or pleasure in your life?
What are your main worries and fears?
What are your most important hopes or dreams?
Is there any other information you would like me to know about you and your situation.

Dr. Debra Mandel-A Professional Psychological Corporation Service Provider:
Debra Mandel, Ph.D.
License #PSY11225 818.335.6309
drdebra@dmdoc.com www.drdebraonline.com

Acknowledgment of Receipt of Office Policies/Consent for Treatment (OPCT)
By signing below, I agree to all the terms set forth in the OPCT form.
Patient's Name*

First NameLast Name
Patient's Signature*

Clear
Date

MonthDayYear
Date
Acknowledgement of Receipt of Telehealth Disclosure (THD):
Patient's Name*

First NameLast Name
Patient's Signature*

Clear
Date

MonthDayYear
Date
I patient name have received a copy of this Office's Notice of Privacy Practices.
Patient's Name*

First NameLast Name
Patient's Signature*

Clear
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

FOR ROUTINE MESSAGES:

FOR CONFIDENTIAL/PRIVATE MESSAGES:

Education

Emergency Contact

CURRENT RELATIONSHIP STATUS:

PRESENT SPOUSE/PARTNER

Family Relationships

MEDICAL DOCTOR(s)

PAST/PRESENT PSYCHOTHERAPY

Social Media