The Stein Wellness Center, Inc

The Stein Wellness Center, Inc.

915 Oakfield Dr. Suite E., Brandon, Fl. 33511

(813) 685-2221 Fax: (813) 681-2208

Carmen T. Stein-McCormick, Ph.D., LMHC-S, CCMHC, NCC

Licensed Mental Health Counselor/Supervisor

Thomas F. McCormick, LMHC, NCC

Licensed Mental Health Counselor

*Eddie Hardison, LMHC *Gretchen Sanchez, LMHC

Licensed Mental Health Counselor Licensed Mental Health Counselor

*Daisy M.D. Bryant, LCSW *Rebecca Harrelson, MS, NCC

Licensed Clinical Social Worker Registered Mental Health Counseling Intern

*Stephani Mendizabal, LMHC, NCC

Licensed Mental Health Counselor

*A group of individual practitioners operating as independent contracting professionals under their own licensure/supervision.

Name______DOB______Age____

Address______

City______State______Zip Code______

Patient’s SSN______

Telephone # (H)______(W)______(C)______

May we call you at home/cell? Y / N Work? Y / N Leave a Message? Y / N

Client’sor Guardian’sPlace of Employment______

Insurance Co.______

I.D.#______Group #______

Name of Owner of Insurance______

SSN of Insurance Owner______

Relation to Client______

Marital Status______Yrs. Married______Prior Marriages______

Number of Children______Ages______

Current Medications______

Prescribing Doctor______

Name of Primary Doctor______

Do you give us permission to discuss your case if needed with him/her? Y / N

Signature______Date______

Emergency Contact:______Phone:______

Relationship:______

ALLERGIES:______

Military Affiliations (if any):______

Who referred you to this office?______

Please describe any history of emotional, behavioral or psychological problems in your or your child’s family:

INSURANCE AUTHORIZATION #______

For children and minors under age 18 years of age.

School:______

Grade:______

Special Classes:______

Behavior Problems:______

Has your child ever been tested by school?______

Does your child have any developmental problems?______

Are the parents divorced?______

Is this evaluation to be used for a divorce proceeding?______

Name of Biological

Mother:______

Phone:______

Name of Biological Father:______

Phone:______

Name of Child’s Legal Guardian (if not parents)

______

Phone:______

Has your child ever been part of a DCAF investigation? Y / N

If Yes, what was the result?

______

Patients Clinical History

Name______Age______

Have you ever been to a therapist or psychiatrist in the past? Y / N Name and Year:______

Adults
Please checkthe symptoms that you are currently experiencing or have experienced.

Problems falling asleep______Child abuse______Over eating______
Over sleeping______Sexual abuse______Loss of appetite______
Depression______Compulsions______Loss of sexual desire____
Drug issues______Hearing voices______Overspending______
Suicidal ideas______Obsessions______Lack of concentration____
Fears______Family deaths______Miscarriages______
Anxiety______Nightmares______Anger______
Cutting______Irritability______Fatigue/Tiredness______
Hair pulling______Rages______Shaking______
Alcohol problems______Sweating restlessness______Marital issues______
Crying______Other issues not mentioned:______
Children
Parents, please check any symptoms your child is experiencing.
Irritable mood______Talks back to adults______Doesn’t stay seated in class______
Discontent/sad______Doesn’t need much sleep______Talks excessively______
Bored______Smokes cigarettes______Has problems going to sleep______
Frequent mood swings______Smokes marijuana______Eats standing up______
Nightmares/terrors______Drinks alcohol______Runs around the house______
Bothered by noise______Has problems remembering______Runs around the classroom______
Inflated self esteem______Blurts out answers______Oppositional behavior______Doesn’t retain information______Interrupts adults______Rages that last over 2 hours______Makes careless mistakes______Destroys property______Periods of increased energy______Can’t stay on task______Unable to pay attention______Excess talking______Doesn’t listen when spoken to______Periods of depression______Hurts himself/herself______Easily distracted______Looses things for tasks______Speaks of dying______Disorganized______Threatens when angered______Risky behaviors______Doesn’t make eye contact______
Other:______

Please describe why you are here today:______

______

How is this problem affecting you? ______

I have read the Consent for Treatment, Financial Policy and the HIPAA policies posted in the waiting room and attached to the clipboard. I fully understand the information, and understand that there are no guarantees or assurances due to these services.

Client or Guardian Signature______Date______