NANTUCKET FAMILY COUNSELING, P.C.
Patient Registration Form
Kindly print, fill out and bring in at the time of your first appointment.
ALL information is kept confidential.
Date of first appointment: ___________________________________
Name: _________________________________Date of Birth: ________________________
If you are here for a child, please list his/her name and date of birth as well.
Address:
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Home Phone: ______________________________ Work Phone: ________________________
Cell Phone: __________________________________E-Mail Address:______________________
May I contact you by e-mail if I need to?_______________________________________________
Health Insurance Plan: _________________________Telephone Number: ___________________
I.D. Number: ________________________________Insured’s Name: ______________________
Insured’s Employer: ___________________________Your Religion: _______________________
Your Occupation: _________________________________ Hours worked per week: ___________
Place of Employment: ________________________ Shift: ______________ Years:____________
Job Responsibilities:_______________________________________________________________
Marital Status:______________ Date of Marriage: __________Years together with partner: _____
Spouse’s / Significant Other’s first name:_______________________________________________
List Each Child’s Name: Age: Grade in School: Sex:
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Were there any difficulties with any of the pregnancies or deliveries? _________________________
You do not need to answer the rest if you are here for your child.
Have you ever served in the military? _______________ If so, when? _______________________
Are there any current or previous legal charges against you? _______________________________
What do you like to do in your spare time? ____________________________________________
Do you have any special talents or hobbies? ____________________________________________
Who referred you for counseling at this time?___________________________________________
Do you drink alcohol? ________________If so, how frequently/how much? __________________
Do you smoke marijuana? ____________If so, how frequently/how much? ___________________
Do you use any non-prescription medications? __________________________________________
Do you have any allergies? _________________________________________________________
How much caffeine do you consume each day? __________________________________________
Do you smoke cigarettes? ___________________ Have you in the past? _____________________
Name of Primary Physician: _______________________ Date of last physical exam: __________
Do I have your permission to communicate with his/her office, if necessary? ___________________
Do you have any physical problems? _________________________________________________
History of Prior Surgeries: __________________________________________________________
Please list any prescription medications you are currently taking:
Name: Start Date: Dosage: Frequency:
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Have you taken any anti-depressant medications in the past and if so, what? ______________________________________________________________________________
What were the results? ____________________________________________________________
Do you have trouble sleeping? ______________________________________________________
How would you describe your appetite? _______________________________________________
Do you or have you ever had panic/anxiety attacks? _____________________________________
Have you ever had thoughts of suicide? _______________________________________________
Have you lost a close friend or family member through death recently?________________________
Do you have any pets? If so, please list: _______________________________________________
Do you have any family members who have suffered from emotional or psychiatric disorders? _____
If so, whom? ____________________________________________________________________
Did you have any learning/attention problems in school?_________________________________
What would you perceive your current stresses to be? __________________________________________________________________________
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What are some of the areas you would like to explore in therapy? __________________________________________________________________________
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Please use the following space to add any information you think may be helpful in the counseling process: ____________________________________________________________________________
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Thank you for taking the time to let me get to know you. |
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