Alan Behrman & Associates, PC

    2876 Johnson Ferry Rd., Suite 150 Marietta, GA 30062
    770-361-7864 anxiety_free@att.net


    Client Information Form

    *This form is completely confidential*

    Telehealth option: If my primary therapy is face-to-face, but an emergency arises on my part or on the part of the therapist or environmental emergency that inhibits one or both of us from being in the office, I am willing to use telehealth as an alternative for that particular session.

    May I have your permission to thank this person for the referral

    If referred by another clinician, would you like for us to communicate with one another?

    Person(s) to notify in case of any emergency:

    I will only contact this person if I believe it is a life or death emergency. Please provide your name to indicate that I may do so:


    *The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.*

    MEDICAL HISTORY:

    Current Medications:

    Do you smoke or use tobacco?

    Do you consume caffeine?

    Do you drink alcohol?

    Do you use any non-prescription drugs?

    Have anyone voiced concern about your substance use?
    Have you ever been in trouble or in risky situations because of your substance use?


    FAMILY:

    Were there any other primary care givers who you had a significant relationship with? If so, please describe how this person may have impacted your life:


    RELATIONSHIPS & SOCIAL SUPPORT & SELF-CARE:

    Previously Married/Life Partnered?


    EDUCATION & CAREER


    Please check all that apply:

    Anxiety

    Depression :
    Mood Changes :
    Anger or Temper :
    Panic :
    Fears :
    Irritability :
    Concentration :
    Headaches :
    Loss of Memory :
    Excessive Worry :
    Feeling Manic :
    Trusting Others :
    Communicating with Others :
    Drugs :
    Alcohol :
    Caffeine :
    Frequent Vomiting :
    Eating Problems :
    Severe Weight Gain :
    Severe Weight Loss :
    Blackouts :

    People in General

    Parents :
    Children :
    Marriage/Partnership :
    Friend(s) :
    Co-Worker(s) :
    Employer :
    Finances :
    Legal Problems :
    Sexual Concerns :
    History of Child Abuse :
    History of Sexual Abuse :
    Domestic Violence :
    Thoughts of Hurting Someone Else :
    Hurting Self :
    Thoughts of Suicide :
    Sleeping Too Much :
    Sleeping Too Little :
    Getting to Sleep :
    Waking Too Early :
    Nightmares :
    Head Injury :

    Nausea

    Abdominal Distress :
    Fainting :
    Dizziness :
    Diarrhea :
    Shortness of Breath :
    Chest Pain :
    Lump in the Throat :
    Sweating :
    Heart Palpitations :
    Muscle Tension :
    Pain in joints :
    Allergies :
    Often Make Careless Mistakes :
    Fidget Frequently :
    Speak Without Thinking :
    Waiting Your Turn :
    Completing Tasks :
    Paying Attention :
    Easily Distracted by Noises :
    Hyperactivity :
    Chills or Hot Flashes :


    FAMILY HISTORY OF (Check all that apply):