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Click here to download form (PDF)
Lee Blackwell, Ph.D.
Date_______________
Patient name________________________________________
Gender: M F Birth date___________________
Fax (____)___________________ Cell
(____)____________________E-Mail_____________________________
Home address____________________________________________________
Home phone (_____)________________
City/state__________________________________________________Zip__________
Driver's License No.____________________ Social Security Number____________________
Occupation_________________ Employer_________________________________________
Business
phone (____)_________________
Business Fax_________________________
Business address___________________________________________________
City/state__________________________________________________Zip___________
Please do NOT contact me
at: Home ____ Business ____
Cell ____ Fax ____ Email ____
Mail ____
Spouse/Partner
Name____________________________________________ Gender: M
F Marital status_________________
Driver's License No.__________________ Social
Security No._________________________
Birth date_______________
E-Mail________________________________ Cell
(____)___________________
Fax
(____)____________________Occupation_____________________
Employer____________________________________
Business phone
(____)_________________
Business
address________________________________________________
City/state_____________________________________________Zip______________
Bus. Fax (____)________________
Please do NOT contact my
partner/spouse at: Home ____ Business ____
Cell ____ Fax ____ Email ____
Mail ____
Other persons living in the home (include name,
birth date and relationship):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Family members or important others living outside
the home (include name, birth date and
relationship):_______________________________________________________________________________________
_________________________________________________________________________________________________
Name, address and telephone number of person
referring you:
_________________________________________________________________________________________________
Physician's name, address and telephone
number:___________________________________________________________
_________________________________________________________________________________________________
Date of last physical examination and
findings:__________________________
___________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
Major physical problems and/or medications
taken:_________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
If previous psychological testing, name, address and
telephone number of tester:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
If previous psychotherapy or counseling, name,
address and telephone number of provider:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Outcome:__________________________________________________________________________________________
_________________________________________________________________________________________________
Reason(s) for seeking consultation now:__________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Describe any family history of major mental illness,
depression, suicide, or alcohol or drug abuse:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
In case of emergency,
contact___________________________________________Phone (_____)_______________
Insurance Information
If this area
is left blank, I will assume you will not need insurance forms sent to
you. To avoid duplication, we can copy
your insurance card, or write “same” in the blanks marked with an *.
Is Condition related to: Employment? Yes____ No____
Auto
Accident? Yes____ No____
Other
Accident? Yes____ No____
Name of
Patient:_______________________________________
Relationship to
Insured:__________________________
Name of
Insured:______________________________________________*SSN:_____________________________
*Address of Insured:_____________________________________________________
*City______________________________________________
*State______ *ZIP___________________
*Telephone:
(____)______________________ *Fax:
(____)_________________________
Insured’s I.D.
Number:________________________________ Sex:_____ *Date of Birth:____________________
Name of Employer or
School:__________________________________________________________________________
Insurance Plan Name or Program
Name:_________________________________________________________________
Insured’s Policy Group or FECA Number:___________________________________________
