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Franklin Sollars and Associates-Counseling and Psychological Services

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Personal Information and Medical Consent Form
 
(Please fill in and print out and form for first session)
 
Name:    ________________________         Date:  ____________
 
Age:   ________   Marital Status:   Single  _____  Married  _____  Divorced      Widowed______
 
 
Childrens Names Ages and Gender if apllicable___________________________________________________________
 
Pleae tell  me why you are coming for therapy at this time:___________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 
 
Please indicate if you are experiencing any of these symptoms:
 
depression (    ) sadness or grief (    )moodiness/irritability(   )
 
Anxiousness (   ) lonliness(   ) stress (   ) tiredness 
 
Tension  (   )    sleep disturbance (   )   low energy  (     )
 
Nightmares (   )   work difficulties (   )   change of appetite (   )
 
Please explain:   _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 
Are you feeling suicidal?  yes (   )no (   )Homocidal: yes (   ) no (   )
 
 Please explain:   _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 
Do you have a problem with alcohol or drugs?  yes  (   )  no  (   )
 
Please explain:________________________________________________________________________________
What medications are you currently taking, why you are taking them, and dosage and frequency.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 
 
Are you experiencing any medical problems at this time?    yes  (   )  no (   )  
Please explain:  _______________________________________________________________________________________
_______________________________________________________________________________________ _______________________________________________________________________________________
 
If so, what physician are you seeing for this?   ( Please provide name, address and phone numbers)
_______________________________________________________________________________________
_______________________________________________________________________________________
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Please describe any current or past involvement with the legal system (civil or criminal ):
_______________________________________________________________________________________
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What is your highest level of education?
 
Pre High School  (   )   High School GED (    )   Associates Degree   (   )   Bachelor's Degree  (   )   Master's Degree  Doctoral Degree  (    )  Currently Enrolled in College  (    ) 
 
What is your field of study?   ___________________________
 
Are you happy with your educational or employment choices? yes (   )   no  (    )     
 
Please explain: ______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 
Please describe briefly your spiritual beliefs and needs if any: _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 
Have you been involved in counseling, therapy, or substance abuse treatment?  yes  (   )  no  (   )
 
Please indicate when with whom and how helpful it was: _________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
 
 
Please describe your relationship with your family of origin:  ______________________________________________________________________________________
______________________________________________________________________________________
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Do you have hobbies or interests? Please explain:  ______________________________________________________________________________________
______________________________________________________________________________________
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How you would describe yourself as a person? ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
 
 
Thank you for your efforts in providing this information. It is very helpful in getting the therapy sarted quickly. This information is strictly confidential and will never be released to anyone without your permission accept where required by law.       

Medical Information and Consent section
 
 
Name: ____________________________
Address:________________________________________________
_______________________________________________________
_______________________________________________________
 
Telephone:_______________________   
 
Email: __________________________      
 
If Applicable, Insurance Subscribers Name:___________________________  Date of Birth:_________
Subscribers Address (if different than Above:_______________________________________________
____________________________________________________
____________________________________________________
Relationship to Subscriber:_____________________________________________
Insurance Company Name:____________________________________________
Billing Claim Address:_________________________________________________
Subscribers Id No: ___________________________________________________
Group No:__________________________________________________________
Phone: ____________________________________________________________
Patients Date of Birth:________________________________________________
 
I authorize any clinical or other information necessary to process my insurance claim according to insurance policy requirements. I also accept esponsibility for payment of co-pays, deductables and non payment of fees not paid to the provider by the insurance company. As customary, I agree to pay my deductable and/or co-pay at the time of services rendered.
 
Patients Signature_______________________________    Date ______________
 
Witness Signature _______________________________   Date ______________
 
Franklin Sollars and Associates Counseling and Psychological Services
725 S. Adams, Birmingham, MI 48009

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Thank You for taking the time to faciliate the therapeutic process

Sollars and Associates_Counseling and Psychological Services * 725 S. Adams Ste 235 * Birmingham ,MI * US * 48009