Patient Record

PATIENT RECORD

Patient:______Date of Birth:___/___/___ *Current Age______

Address: ______City:______State: ____ Zip: ______

Cell Phone: (____) ______Home Telephone: (____) ______Work Telephone (____)______

Sex: MaleFemale Subscriber S.S.#: ______-______-______*If under 18-yrs-old, parental consent needed

Employer/School Job Title/Grade

Marital Status: Married Single Divorced Widowed Partner’s Name______

Emergency Contact:______Telephone:(____) ______

Guardianship Information (if relevant):

Name:______Address:______Contact Number:______

Relevant medical conditions (history, current condition, changes in condition):

______

Medications (dosage, dates of initial prescriptions, name of prescribing professional):

Allergies/adverse reactions to treatment:

Primary Care Physician Name: ______Telephone ______

Address:______City______Zip______

Date of last medical/physical exam______

Reason for seeking therapy______

______

______

Treatment Goals______

______

Past psychological or psychiatric treatment______

______

Psychiatric hospitalizations (Dates and Locations) : ______

______

Family History of psychological or psychiatric treatment ______

Do you drink coffee? Y or N (#_____cups/daily) Do you smoke Cigarettes? Y or N (#_____per day)

Alcohol? Y or N (#______drinks weekly) Date last drank______Family History of Alcoholism? Y or N

Marijuana use (past or present) Y or N Date last used______Other street drug use (past of present) Y or N

Street drugs: Type______Amount ______Frequency______Date last used______

Police / Probation involvement (past or present) Y or N Date______Please explain ______

______

Family Structure (who lives in your household? Please provide names, ages and relationship to each) ______

______

Please circle if you have experienced any of the following (past or present):

Domestic Violence Traumas Sexual Abuse Physical Abuse

Sleep Problems Eating Disorders Losses Learning Problems

Suicide Attempts Suicidal Ideation Auditory Hallucinations Visual Hallucinations

Spending Sprees Outbursts of Anger Lying Phobias

Mood Changes Worry/Fear Panic Attacks Poor Concentration

Tearfulness Fatigue Feeling Hopeless/Helpless Head Injury or Seizures

Religious preference ______

What are your strengths ______

What are your weaknesses ______

Motivation for treatment______

Any other information you believe may be significant______

______

______

______

Patient’s Signature______Date______

Provider’s Signature______Date______

Pamela Hollings, LCSW

300 Carlsbad Village Drive, #216

Carlsbad, CA 92008 (619) 624-0735

Credit Card Authorization Form

Please complete the following information. This form will be securely stored in your clinical file and may be updated upon request at any time.

In case of late cancellations and/or no shows for scheduled sessions, your credit card will be charged the full session fee of $125. If a balance accrues due to an unmet deductible with your insurance company, an unpaid balance from your insurance company, or if a personal check is returned unpaid, your credit card will be charged for the unpaid balance. An additional $35 is assessed for returned checks.

I, ______, am authorizing Pamela Hollings, LCSW, to use my credit card information to charge my credit card in the event that I do not notify her of my inability to attend a scheduled therapy appointment, do not cancel my appointment at least 24 hours in advance, a check is returned for any reason or there is an outstanding balance after 30 days.

Type of Card: VISA  MasterCard  Exp. Date: _____/______

Name on Card: ______

Card Number: ______-______-______

Verification/Security Code (3 digit code on back of card by signature line): ______

Billing Address:______

City:______State: ______Zip:______

By signing below I am authorizing Pamela Hollings, LCSW to charge my credit card for scheduled appointments or outstanding balances after 30 days.

Signature:______Date:______

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