Sadar Psychological and Sports Center

Client Information Date:

First Name, Middle Initial
Last Name
Address
City, State, Zip Code
Name of Person Responsible for Bill
Referred By
Relationship to referral source
Birth Date mm/dd/yyyy
Gender M F
Marital Status - Circle One Single Married Separated Divorced Widow(er)
Occupation / Employer
School / Grade
Contact Information Phone Okay to leave message?
Work Phone Y or N
Home Phone Y or N
Cell Phone Y or N
Email
Medical Information
Family Physician Name
Family Physician Address

Family Physician Phone

Current Medication(s)

Allergies
Household Members - Name Relationship / Age / Grade or Occupation

Office Use Only

Special Needs

Alert

Therapist

Date Office Entered Into Scheduler

Entered by (initials)
Login
Password
Client Shown How to Use Scheduler Y N
Date Client Shown
Client Initials

For Therapist Use Only

Presenting Problem:

History:

Current Situation:

Mental Status:

Diagnosis/Impression:

Plan:
For Dependents Only
Father's Name
Address
City, State, Zip Code
Birth Date mm/dd/yyyy
Employer/Occupation
Contact Information Phone Okay to leave message?
Work Phone Y or N
Home Phone Y or N
Cell Phone Y or N
Email
Mother's Name
Address
City, State, Zip Code
Birth Date mm/dd/yyyy
Employer/Occupation
Contact Information Phone Okay to leave message?
Work Phone Y or N
Home Phone Y or N
Cell Phone Y or N
Email
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