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psychiatric problem;  recent traumatic experience;  socially withdrawn;  suspected abuse;  temper/anger/aggression;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.

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Signature (or signature of parent or guardian, if required) date