Benna Z. Sherman, Ph.D.
Licensed Psychologist
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Patient Information Form
Mr./Mrs./Ms./Dr. ________________________________
Address: ______________________________________
______________________________________________
______________________________________________
Phone #: (put a * next to preferred contact #, where a message may be left)
(home)______________________________
(work)_______________________________
(mobile)_____________________________
Email (optional)__________________________________
Marital/partnership status: ________________________________
Date of Birth: _______________
Household members (name, relationship, date of birth):
_______________________________________ ____________________________________
_______________________________________ ____________________________________
Employer: ____________________________________
position: _____________________________
And/or
Current school: ________________________________ grade: ____
Years of Education/Degree__________________
Referred by/Knew about from: ____________________________
Primary care physician: ______________________________
Phone #: ________________________
Any medical problems or conditions? _________________________________________________________________
Medications? __________________________________________________________________________________
Allergies? _____________________________________________________________________________________
Date of last medical exam/evaluation ___________________
Prior therapy? __ yes __ no
with whom? ___________________________________ when? _______________
Financial responsibility for psychological services
Responsible party, if different from patient:
_____________________________________
Address and phone, if different from patient:
____________________________________
____________________________________
phone #: (H)_________________(W)_________________
(10/10)
