CHERYL K.C. ANDAYA, Psy.D., LLC
Date:______________
Name:___________________________________________
Address: _____________________________________Zipcode_________
Phone Numbers: Home _____________________ Work______________________Cell__________________
Social Security # _________________________ Age ______
Date
of Birth______________
Employer____________________________________________
Occupation (major if Student)___________________ Address___________________________________________________________
Person to Contact in Case of Emergency______________________________________
Address____________________________________________________________
Phone________________ Relationship________________________________
Health Insurance
Company_______________________________________________________ Address_________________________________________________________
Phone _______________________
Policy # ______________________ Group#_______________________
Subscriber________________________________________________
Subscriber Date of Birth_______________________
Physical/Emotional Concerns (X if problem, ? if possible problem or you are unsure)
| _____ Heart Problems | _____ Stress |
| _____ High blood Pressure | _____ Anxiety |
| _____ Gastro-Intestinal (Stomach) Problems | _____ Depression |
| _____ Respiratory(Breathing) Problems | _____Mood Swings |
| _____ Sleep Problems | _____ Suicidal Feelings |
| _____ Eating Problem/Concern | _____ Past Suicide Attempt (s) |
| _____ Headaches | _____ Grief/Loss |
| _____ Drug/Alcohol Problem | _____ Sexual Abuse/Incest |
| _____ Other Health Problem (explain) _______________________________ |
_____ Other (explain) _______________________________ |
Do You Use Alcohol?____Yes____No
If Yes, How Much and How Often_______________________________________________
Do You Use Non Prescription Medications or Illegal Drugs?____Yes____No
If Yes, What type and How Often__________________________________________________
If taking prescription medication, what type (s) and what for?________________________________________________
Have You Ever Had Counseling Before?____Yes____No
If Yes, In what situation?______________________________________
Name and Address Of Counselor____________________________________
Appointment and Payment Policies
Sessions are 45-50 minutes in length. Payment or insurance co-payment is due at time of session. If unable to keep a scheduled appointment you must call to cancel 24 hours in advance, without this cancellation you are still responsible for payment in full. Insurance companies will not pay for missed/appointments. Your signature indicates that you have read and agree with these terms, and represents your consent for release of information to your insurance company for billing/payment purposes.
Client______________________________________ Date _______________
