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Ahwatukee Psychological Services, PLLC
Testing, Diagnosis and Treatment: Comprehensive Clinical Psychological Services for Individuals, Couples, & Families

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.

________________________________________________________        ______________________

Patient Signature                                                                                     Date

________________________________________________________        ______________________

Guardian Signature (if under 18)                                                        Date

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