CONFIDENTIAL PERSONAL INFORMATION
Today's Date: ___________________ How did you hear about Dr. Demner? Internet; Parkland Life; Other: ____________________
Patient's Name: _____________________________ Sex: M F O Birth Date: ____________ Age: ____________
Address: ___________________________ City: _____________ St: ___ Zip: _______
Phone: (Home) ______________ (Cell) ________________ (Home) ______________ Email: _____________________
Patient's Occupation: ____________________ Employed by: _______________________
Marital Status: S M D W If Married, Spouse's Name: ______________________________
Spouse's Occupation: ____________________ Employed by: ______________________
Number of years married: ___________ Number of Children: _________
If Minor, Mother's Name: ____________ Father's Name: ______________
Name of Person Financially Responsible: _________________________________
Briefly Describe Reason for Seeking Counseling: ____________________________________________________________________________________
____________________________________________________________________________________________________________________________
Length of Time Problem Has Existed: ____________ Last Medical Exam: _____
Physician: _____________ Known Medical Problems: ________________
Current Medications: ___________________________________________________________________________________________________________
List Previous Psychiatric, Psychological, or Counseling Treatment:
Therapist: ________________ Year: _________ How Long? __________________
Therapist: ________________ Year: _________ How Long? __________________
Amy Demner, Ph.D., LMHC, FAACS, ATR-BC
5441 University Dr., Ste. #101, Coral Springs, FL 33067
Email: dramy@dramycom Phone: 954-346-7066 Web site: dramy.com
Today's Date: ___________________ How did you hear about Dr. Demner? Internet; Parkland Life; Other: ____________________
Patient's Name: _____________________________ Sex: M F O Birth Date: ____________ Age: ____________
Address: ___________________________ City: _____________ St: ___ Zip: _______
Phone: (Home) ______________ (Cell) ________________ (Home) ______________ Email: _____________________
Patient's Occupation: ____________________ Employed by: _______________________
Marital Status: S M D W If Married, Spouse's Name: ______________________________
Spouse's Occupation: ____________________ Employed by: ______________________
Number of years married: ___________ Number of Children: _________
If Minor, Mother's Name: ____________ Father's Name: ______________
Name of Person Financially Responsible: _________________________________
Briefly Describe Reason for Seeking Counseling: ____________________________________________________________________________________
____________________________________________________________________________________________________________________________
Length of Time Problem Has Existed: ____________ Last Medical Exam: _____
Physician: _____________ Known Medical Problems: ________________
Current Medications: ___________________________________________________________________________________________________________
List Previous Psychiatric, Psychological, or Counseling Treatment:
Therapist: ________________ Year: _________ How Long? __________________
Therapist: ________________ Year: _________ How Long? __________________
Amy Demner, Ph.D., LMHC, FAACS, ATR-BC
5441 University Dr., Ste. #101, Coral Springs, FL 33067
Email: dramy@dramycom Phone: 954-346-7066 Web site: dramy.com