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Psychological Services

Psychological testing and treatment

for Individuals, Couples, and Families.

Family
Woman Blowing on Flower

Registration

Ahwatukee Psychological Services

Dr. Astrid Heathcote, Psy.D
10429 S. 51st St.
Suite 210C
Phoenix, AZ 85044

Intake Form

 

Name:________________________________________________________________________________________________________________________________

                        (Last)                                                                                  (First)                                                                      (M.I.) 

Name of parent/ guardian (if under 18 years):

______________________________________________________________________________________________________________________________________

                        (Last)                                                                                 (First)                                                                       (M.I.)

Birth Date: ________/________/_______   Age:_______  Gender: _____Male _____Female

Marital Status:

                        _____Never Married  _____ Domestic Partnership  _____Married

                        _____Separated              _____Divorced                  _____Widowed

Please List any children/age: __________________________________________________________________________________________________________________

Address:_________________________________________________________________________________________________________________________________________         

Home Phone: (_____)- ______- _________ May we leave a message? _____Yes  _____No

Cell/ Other Phone: (_____) -______-__________ May we leave a message? ______Yes  _____No _____Text

Email:________________________________________ May we email you? ____Yes  ____No

*Please note: Email correspondence is not considered to be a confidential medium of communication

Referred by (if any): ____________________________________________________________

Emergency Contact: ____________________________________    Relationship:_____________________________ Phone:_______________________________

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

_____No  _____Yes, Previous therapist/practitioner: _________________________________________________

Are you currently taking any prescription medication?

______Yes.  ______No

Please list: ___________________________________________________________________________________________________________________________________________
___________________________________________________________________

Have you ever been prescribed psychiatric medication?

___Yes

___No

Please list and provide dates: ________________________________________________________________________________________________________________________________________________________

__________________________________________________________________

 

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your physical health? (Please circle)

Poor                Unsatisfactory            Satisfactory                Good               Very Good

Please list any specific health problems you are currently experiencing:

_______________________________________________________________________________________________________________________________________________________

2. How would you rate your current sleeping habits? (please circle)

Poor                Unsatisfactory           Satisfactory                Good               Very Good

Please list any specific sleep problems you are currently experiencing:

_____________________________________________________________________________________________________________________________________________________

3. How many times per week do you generally exercise? _________________

What type of exercise do you participate in:

__________________________________________________________________________________________________________________

4. Please list any difficulties you experience with your appetite or eating patterns:

__________________________________________________________________________________________________________________

5. Are you currently experiencing overwhelming sadness, grief or depression?

_______No  _______Yes

If yes, for approximately how long?___________________________________________________________________________

6. Are you currently experiencing anxiety, panic attacks or have any phobias?

______No  ______Yes

If yes, when you begin experiencing this? ___________________________________________________________________

7. Are you currently experiencing any chronic pain?

______No ______Yes

If yes, please describe: _______________________________________________________________________________________

8. Do you drink alcohol more than once a week?  ____Yes ____No

9. How often do you engage in recreational drug use? 

____Daily            ____Weekly              ____Monthly            ____Infrequently            ____Never

10. Are you currently in a romantic relationship? ______Yes     _______No

If yes,  for how long? ___________________________________________________________________________________________

On a scale from 1-1-, how would you rate your relationship? ________________

 

11. What significant life changes or stressful events have you experienced recently?

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

 

FAMILY MENTAL HEALTH HISTORY:

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)

                                                                       

                                                                       Please Circle                        List Family Member

Alcohol/Substance Abuse                            Yes/No

Anxiety                                                               Yes/No

Depression                                                        Yes/No

Domestic Violence                                           Yes/No

Eating Disorders                                                Yes/No

Obesity                                                                Yes/No

Obsessive Compulsive Behavior                    Yes/No

Schizophrenia                                                    Yes/No

Suicide Attempts                                               Yes/No

 

ADDITIONAL INFORMATION:

1. Are you currently employed?     ______Yes    ______No

If yes, what is your current employment situation:

_________________________________________________________________________________________________

Do you enjoy your work? Is there anything stressful about your current work?

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

 

2. Do you consider yourself to be spiritual or religious? _____Yes    _____No

If yes, describe your faith or belief:

_________________________________________________________________________________________________

 

3. What do you consider to be some of your strengths?

____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

 

4. What do you consider to be some of your weaknesses?

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

 

5. What would you like to accomplish out of your time in therapy?

______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________

 

Insurance information:

Primary Insurance Carrier_____________________________________________________________________

Insured/Subscriber___________________________________________________________________________

Relationship to subscriber____________________________________________________________________

ID Number______________________________________________________

Group Number__________________________________________________

 

I authorize the release of any medical records or other information necessary to process my medical claims.

_________________________________________________________        ______________________

Patient Signature                                                                           Date

_________________________________________________________        ______________________

Guardian Signature ( if under 18)                                          Date

 

I authorize payment of medical benefits to Ahwatukee Psychological Services PLLC (Dr. Astrid Heathcote Psy. D) for any and all psychological services performed. I understand that I am financially responsible for the charges not covered by my insurance. Also in the event that an appointment is missed without 48 hours notice, I understand that my credit card will be automatically charged with the full fee of $200.

_________________________________________________________     ______________________

Patient Signature                                                           Date

_________________________________________________________     ______________________

Guardian Signature (if under 18)                                    Date

 

I have read and agree to all terms and conditions illustrated in the “Informed Consent About Therapy” document (pg. 1-7). I understand and will abide by its items during our professional relationship.

________________________________________________________        ______________________

Patient Signature                                                            Date

________________________________________________________        ______________________

Guardian Signature (if under 18)                                     Date

 

I understand that Dr. Heathcote reserves the right to discontinue services/refer to other resources if the patient misses 3 appointments with out 48-hour notice.

i understand that Dr. Heathcote will determine during my first visit if she can meet the patient's treatment needs or if a referral to an agency or different therapist may be helpful to the patient..

________________________________________________________        ______________________

Patient Signature                                                            Date

________________________________________________________        ______________________

Guardian Signature (if under 18)                                     Date