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Individual Client Information (Confidential)
Bellagio Psychotherapeutics – Dr. Mark Zuccolo
Date
First Name
*
Last Name
*
Email Address
*
Street Address
*
Apartment, suite, etc.
City
*
State
*
ZIP / Postal Code
*
Cell Phone
*
May we leave a voice mail on your cell phone?
*
Yes
No
Home Phone
May we leave a voice mail on your home phone?
Yes
No
Preferred appointment reminder
*
Email me the appointment reminder the day before
Text me the appointment reminder the day before
Your Age
*
Birthdate
*
Relationship status
*
Single
Married
Life partner
Separated
Divorced
Widowed
Who lives with you?
*
Spouse or significant other
Family of origin
Friend or roommate(s)
I live alone
Emergency contact person
*
Emergency Contact Phone
*
Occupation
Employed full time
Employed part time
Full time parent
Student or intern
Retired
Other
Briefly describe the issue you need to discuss
*
On a scale of 0-10 how distressed are you by this issue?
*
0=not at all - 10=Extremely
On a scale of 0-10 how well are you functioning in life?
*
0=not at all - 10=Very well
Physical or mental symptoms and distressing situations
*
Abuse of illicit or prescriptions drugs
Abuse of alcohol
Workplace conflict
Financial difficulties
Legal system involvement
Relationship conflict
Anxiety, phobias, panic
Sadness, depression, grief
Anger, temper outbursts
Fatigue, low energy, low motivation
Wide mood swings (euphoria to very low)
Suicide ideation, self-harm, attempts
Problems with appetite, eating disorders
Problems with sleeping, insomnia
Attention, focus, concentration deficit
Recent or resurgent traumatic event
Abuse, violence, exploitation victim
Check all that apply
Medical or mental conditions
Illness(es) or disorder(s) for which you're being treated by a physician or psychiatrist
Current medications
Medications prescribed by a physician or psychiatrist
Childhood environment
Childhood Environment & Sibling Position (e.g., 2 biological parents, blended stepfamily, adopted; oldest child, middle child)
Spiritual beliefs
e.g., spiritual, religious, in ministry, none
Have you had counseling before?
*
Individual counseling
Couples counseling
Family counseling
Never
How did you hear about us?
*
Submit
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