Michael Feeley, PhD

Licensed Psychologist -- Caring and Compassionate Help with Life Goals and Problems.

Appointments during the coronavirus pandemic use video and phone calls.

If you have any questions, please call me at 1-888-933-3539.

Stay safe.

You are here: Home -> Intake Forms and My Schedule -> Informed Consent for Telepsychological Services

New Client Questionnaire

Today's Date:


Identifying Information:

Name:

Address:

City: State: PA Zip:

Date of Birth: Current age:

Marital Status:

Gender: Male Female Other:

Ethnicity: Religion:

Home Phone: May we leave a message here? Yes No

Work Phone: May we leave a message here? Yes No

Cell Phone: May we leave a message here? Yes No

Email: May we contact you via email? Yes No

How do you prefer to be contacted?


Insurance Information:

If you enter treatment with me for psychological problems, will you be using your insurance? Yes No

Insurance Carrier: ID#:

Insurance Holder name: Relation:

Group#: Insurance Holder Date of Birth:


Emergency Contact Information:

Emergency contact person :

Address:

Phone #:

Relationship to you:


Presenting Concerns:

What brings you in for services?


What would be your goals?

How did you find me? Who referred you?


Medical Information:

Primary Care Physician: Phone #:

Address:

City: State: Zip:

If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed and we can coordinate your treatment? Yes No.

(If yes, you will need to sign a “release of information form” in order for me to contact your physician.)


Past Medical History:

Please check any current or past experiences with the following:

Anemia

Problems with Vision

Congestive Heart Failure

Atrial Fibrillation

Hearing Difficulties

Inflammatory Bowel Syndrome

Asthma

Numbness/Tingling

Weight Gain

HIV/AIDS

Head Injuries

Irritable Bowel Syndrome

Shortness of Breath

Stomach Ulcer

Weight loss

COPD

Nausea/vomiting

Sleep Difficulties

Chronic Pain

Cancer

Jaundice

Chronic Cough

Heartburn/Reflux

Diabetes

Skin Problems

Stroke

Kidney/Bladder Problems

Glaucoma

Chronic Lung disease

Diverticulitis

Sickle Cell

Hernia

Pacemaker

Fatigue

Thyroid Disease

Emphysema

Heart Attack

Colon Polyps

Pancreatitis/Liver Disease

Seizures

Headaches

Sexual Dysfunction

High Blood Pressure

Transfusions

Other: _____________________


Past Surgical History:

Please check any past history with the following:


Appendix

Heart

Knee

Back

Gallbladder

Hysterectomy

Heart Valve Replacement

Stomach

Colon

Hip

Other:

Other:









Medications:

Prescribed or over-the-counter

Medication

Dosage/Frequency

Condition

Prescribing Physician


Family Medical History:

Have your family members struggled with the following?


Depression Yes No Relative:

Bi-Polar Illness Yes No Relative:

Heart Disease Yes No Relative:

Diabetes Yes No Relative:

Dementia Yes No Relative:

Schizophrenia Yes No Relative:

Anxiety Yes No Relative:

Eating Disorder Yes No Relative:

ADHD Yes No Relative:

Seizures Yes No Relative:

Alcohol/Drug Problem Yes No Relative:

Asthma Yes No Relative:

Blood Pressure Yes No Relative:

Stroke Yes No Relative:

Cancer Yes No Relative:





Legal history

If yes to any items below, please give a brief description


Have you ever been arrested? (including a DUI – Driving Under the Influence) Yes No.


Have you ever been in prison? Yes No.


Are you presently being sued, suing anyone or thinking of suing anyone? Yes No.


Is your reason for coming to see me related to an accident or injury? Yes No.


3. Are you required by a court, the police, or a probation/parole officer to have this appointment?

Yes No.


Substance Use:

Have you ever used the following substances?


Substance

Y/N

Current Use?

Amount

How often?

Is this something you would like to change?

Alcohol

Yes No.

Yes No.

Yes No.

Marijuana

Yes No.

Yes No.

Yes No.

Cocaine

Yes No.

Yes No.

Yes No.

Opiates

Yes No.

Yes No.

Yes No.

Amphetamines

Yes No.

Yes No.

Yes No.

Hallucinogens

Yes No.

Yes No.

Yes No.

Do you use tobacco products? Yes No Cigarettes Chew

Do you gamble or bet? Yes No How often?

Do you or family, friends or employers have concerns about your gambling? Yes No

How many hours a day do you spend online?

Do you feel your technology use is balanced and healthy, or could it be improved?



Previous Behavioral Health Services:

(such as with a Psychologist, Social Worker, Psychiatrist, Counselor or Psychological Testing)


With Whom

When

Type of

Treatment

Were you hospitalized?

Where?

Yes No

Yes No

Yes No

Yes No

Yes No

Was anything in your previous treatment(s) particularly helpful? Not helpful?

Current Problems:

How often have you experienced the following?

Problem

Never

Sometimes

Often

Always

Excessive Sadness

Nervousness

Racing Thoughts

Low Energy

High Energy

Suicidal Thoughts

Have you ever attempted suicide?

Yes No

Thoughts of Harming Others

Sense of Hopelessness

Panic

Angry Outbursts

Increased Appetite

Decreased Appetite

Sleep Difficulties

Problems related to eating

Hallucinations

Trouble Concentrating

Problem

Never

Sometimes

Often

Always

Irritability

High anxiety

Worry

Self Abuse (i.e., cutting/burning)


Employment/Education:

Current Occupation:

Years in field:

Current Employer:

Relevant Past employment:

Highest level of education attained:

Are you currently enrolled in school? Yes No

If yes, what type of education are you receiving?



Current Living Situation: Who is currently living with you?


Person

Age

Relationship




Your signature: Today's date:



My signature: Date reviewed with you:



Thank you for completing the questionnaire.


If you have any questions or would like to schedule an appointment, please call: 888-933-3539.

I’d be happy to speak with you.

Mike Feeley