Ross L. Mayberry Ph.D.
2800 East Madison Street, # 306 WA Licensed Psychologist #1297 Seattle, WA 98112
(206) 323-7323
New Client Information
Personal Information:
Name: Date of birth:
Address: SS#
Employer/School:
Home phone: Cell: Work:
Email:
May I call you at home/cell ? Yes No At work? Yes No
Are you? Single Married / Partnered Separated Divorced Widowed
Who referred you / What website ?
Medical Information:
Primary Care Physician: Location/Phone:
Are you currently being treated for any conditions? If so, please list condition and treating doctor:
Do you regularly take any prescription medicines? Yes No If so, please provide the following:
May I send a brief summary of your treatment to your doctor? Yes No
Previous treatment: outpatient therapy; outpatient substance abuse; inpatient psychiatric; inpatient substance abuse
Please describe the concerns that bring you here today: Over …
Please check any of the following difficulties that seem to apply to you:
ADHD; anxiety/fears; anger/irritability; alcohol, drugs or other addiction ; child behavior problems;
chronic pain; depression; divorce adjustment; eating; family conflict; gambling; grief/loss;
history of abuse; legal problems; marital/relationship problems; obsessions; panic attacks; poor
concentration / distractibility; sexual issues; sleep problems; stress/feeling overwhelmed; social anxiety;
suicidal urges; traumatic experience; work; other .
If your child is the client, please check any of the following difficulties that seem to apply to your child:
academic/school problems; ADHD; alcohol or drug use; anxiety/fears; behavior problems at school;
chronic health problems; depression; eating disorder; learning disability; legal problems; moodiness;
problems with peers; oppositional/defiant; parental divorce; parent with alcohol or drug problem; parent with
psychiatric problem; recent traumatic experience; socially withdrawn; suspected abuse; temper/anger/aggression;
Other: .
Insurance Information:
Primary Insurance: Secondary Insurance:
Insurance Plan Name: Insurance Plan Name:
Name of subscriber: Name of subscriber:
Member ID#: Member ID#:
Group #:: Date of birth: ______Group #: Date of birth: ______
Claims Address: Claims Address:
Insured’s SS#: Insured’s SS#:
Insured’s address & phone: Insured’s address & phone:
Person responsible for bill: Person responsible for bill:
Assignment and Release: I authorize my insurance benefits to be paid directly to the provider. I am responsible for any balance due.I authorize the provider or insurance company to release information required to process my claims. I authorize all necessary treatment and I agree to pay all fees and charges for such treatment.
X
Signature (or signature of parent or guardian, if required) date