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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? *YesNo

Home Phone

May we leave a voice mail on your home phone?YesNo

Preferred appointment reminder *Email me the appointment reminder the day beforeText me the appointment reminder the day before

Your Age *

Birthdate *

Relationship status *SingleMarriedLife partnerSeparatedDivorcedWidowed

Who lives with you? *Spouse or significant otherFamily of originFriend or roommate(s)I live alone

Emergency contact person *

Emergency Contact Phone *

OccupationEmployed full timeEmployed part timeFull time parentStudent or internRetiredOther

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 drugsAbuse of alcoholWorkplace conflictFinancial difficultiesLegal system involvementRelationship conflictAnxiety, phobias, panicSadness, depression, griefAnger, temper outburstsFatigue, low energy, low motivationWide mood swings (euphoria to very low)Suicide ideation, self-harm, attemptsProblems with appetite, eating disordersProblems with sleeping, insomniaAttention, focus, concentration deficitRecent or resurgent traumatic eventAbuse, violence, exploitation victimCheck all that apply

Medical or mental conditionsIllness(es) or disorder(s) for which you're being treated by a physician or psychiatrist

Current medicationsMedications prescribed by a physician or psychiatrist

Childhood environmentChildhood Environment & Sibling Position (e.g., 2 biological parents, blended stepfamily, adopted; oldest child, middle child)

Spiritual beliefse.g., spiritual, religious, in ministry, none

Have you had counseling before? *Individual counselingCouples counselingFamily counselingNever

How did you hear about us? *

Dr. Mark R. Zuccolo, PhD, LMFT

Serving Alpharetta, Johns Creek, Milton, Cumming, Roswell and surrounding areas — and all of Georgia and South Carolina via telehealth.

Bellagio Psychotherapeutics

5755 North Point Parkway, Suite 33
Alpharetta, Georgia 30022

Contact

(678) 554 5632
appointments@bellagiopsych.com

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