Douglas E Webb Jr, Ph.D.
Licensed Psychologist #1600 (Georgia)
1459 Oxford Road, Suite 301
Atlanta, GA 30307 404-216-9690
FEDERAL TAX ID: 65-1247546
Client Information Form
Today's date: ______
Your name: ______
Last First Middle Initial
Date of birth: ______Social Security #: OPTIONAL
Home street address: ______
City: ______State:
______Zip:______
Name of Employer:______
If you have a work telephone number, is it acceptable for me to call you at that number?
______
Home Phone: ______Work Phone: ______
Cell Phone: ______Email: ______
May I text you? ______
______
Referred by: ______
- May I have your permission to thank this person for the referral?
Yes No
- If referred by another clinician, would you like for us to communicate with one another?
Yes No
Person(s) to notify in case of any emergency: ______
Name Phone
I will only contact this person if I believe it is a life or death emergency. Please provide your signature to indicate that I may do so: (Your Signature): ______
Please briefly describe your presenting concern(s): ______
______
What are your goals for therapy? ______
______
______
How long do you expect to be in therapy in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)? ______
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PLEASE RATE EACH ITEM, INDICATING HOW MUCH THIS ISSUE CONCERNS YOU NOW
(0=not a concern; 1= mild concern; 2= moderate concern; 3=strong concern; 4=crisis)
Physical Health Problems:
Anxiety or Fears
Worry or Rumination
Anger or Irritability
Panic
Dizziness
Headaches
Depression
Mood instability
Partnership problems
Work Relationships
Work Stress
Attention - Concentration
Memory
Productivity
Organization
Avoidance behaviors
Tension in Body
Trusting Others
Difficulty Sleeping
Thoughts of hurting self/self-harming behavior
Thoughts of Suicide/Suicide Attempts
Overuse of Alcohol
Overuse of Drugs
Food Issues
Weight Issues
Nightmares/Posttraumatic Dreams
Aggressive Toward Others
Posttraumatic Memories
Domestic Violence
Past or Current Abuse
Other
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*The following information on this form will help guide your treatment.
Please try to fill out as much as you are comfortable disclosing.*
MEDICAL HISTORY:
Please explain any significant medical problems, symptoms, or illnesses: ______
______
Current Medications:
Name of MedicationDosage Purpose Name of Prescribing Doctor
Do you smoke or use tobacco? YESNOIf YES, how much per day?______
Do you consume caffeine? YESNOIf YES, how much per day? ______
Do you drink alcohol? YES NO If YES, how much per day/week/month/year? ____
Do you use any non-prescription drugs? YES NO
If YES, what kinds and how often? ______
Have any of your friends or family members voiced concern about your substance use? YES NO
Have you ever been in trouble or in risky situations because of your substance use? YES NO
Previous medical hospitalizations (Approximate dates and reasons):______
______
______
Previous psychiatric hospitalizations (Approximate dates and reasons):______
______
______Have you ever talked with a psychiatrist, psychologist, or other mental health professional? YES NO
(Please list approximate dates and reasons): ______
______
Height ______Weight (if applicable) ______Age______Gender ______
Sexual Identity: Heterosexual__ Lesbian__ Gay__ Bisexual__ Transgender__ In Question__
FAMILY:
How would you describe your relationship with your mother/primary caregiver? ______
______
______Living/Deceased_____
How would you describe your relationship with your father/other primary caregiver?______
______Living/Deceased_____
Were/are your parents married?______If parents divorced/unmarried, when and how did their relationship change? ______
______
Were there any other primary care givers with whom you had a significant relationship (grandparent/step parent/other)? If so, please describe how this person’s role in your life and impact they may have had:______
______
Was anyone in your family physically harmful or sexually inappropriate ? If so, whom? What age were you? ______
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How many sisters do you have? ______Ages? ______
How many brothers do you have? ______Ages? ______
How would you describe your relationships with your siblings? ______
______
RELATIONSHIPS & SOCIAL SUPPORT & SELF-CARE:
POOR EXCELLENT
Currently in Relationship? ____ How Long? ____ Relationship Satisfaction: 1 2 3 4 5 6 7
Married/Life Partnered? _____ How Long? ____ Previously Married/Life Partnered? YES NO
If so, length of previous marriages/committed partnerships______
Do you have Children?____ If YES, names & ages:______
Describe any problems any of your children are having: ______
______
List the relationships and ages of those living in your household: ______
______
Please briefly describe any history of abuse, neglect and/or other trauma: ______
____________
POOR EXCELLENT
Current level of satisfaction with your friends and social support: 1 2 3 4 5 6 7
Is spirituality important in your life and if so please explain: ______
______
Briefly describe your diet and exercise patterns:______
______
EDUCATION & CAREER
High School/GED___ College Degree___ Graduate Degree(or Higher)___ Vocational Degree___
What is your current employment? ______