Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 (Page 6 of 8) in pdf

Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 6

Neal Brugman, Psy.D.

(720) 295-7605

Client Information Form

General Information:

Name: ____________________________________ Date of Birth: __________________________

Address: ____________________________________________________________________________

City:______________________________ State: _______ Zip Code: ________________________

Primary Phone: __________________________Secondary Phone: _____________________

Is it ok to leave private/confidential messages at these numbers? Yes No

Email address: ________________________________________________________________

Is it ok to have billing statements sent to this email address? Yes No

How did you hear about my practice?

Name: ______________________________ May I contact this person to thank them? Yes No

Medical Information:

Primary Care Physician (PCP) name: _____________________________________________________

Current medical conditions: _______________________________________________________________

Current medications (list all):______________________________________________________________

Date of last physical examination/PCP visit: ________________

Past Mental Health Treatment:

Name of Therapist: _________________________________________________________

Dates of Treatment: ________________________________________________________

Reason for Treatment: _____________________________________________________

Have you ever been hospitalized for a psychiatric reason? Yes No

Have you ever made a suicide attempt? Yes No

Psychiatric medications (past/current): __________________________________________________

The Collaborative Center, LLC

Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 6