Nahal Delpassand, PsyD, PLLC

Licensed Psychologist

1600 W. 38th St. Suite 428

Austin, TX 78731

512-454-3685

New Patient Intake Form

Presenting Problem
Did a specific event lead to this request for service?
What part of your life does this problem affect you the most? Then rate each on scale of 1-10 ? (0- Not at all 10- significant affect)
Personally
Family Life
Socially
Work-wise
How were you referred to this service? (Please check box) 

Please look these items over and check what best describes how these symptoms have bothered you recently.
Do any of the following concerns contribute to your symptom(s)? (Check all that apply)

Mental Health & Medical History

Are you currently taking any medications?
Have you ever taken any medications for depression, anxiety, or mental health issues?
Do you have any allergies to medications?
If you think it would be helpful for your therapist to contact a previous therapist or physician, you will need to sign a Release of Information form.
Have you ever been hospitalized for mental or nervous problems?

Substance Use

Do you have a substance abuse issues. If yes, please describe substance use.
Have you ever experienced any of the following as a result of substance use? Blackouts, bad reactions, withdrawal symptoms, overdose, DUI, other:
Do you have any spiritual beliefs or practices that are important to you ?
Family Information

Please list those who you consider part of your immediate family and/or your current household.

Living with you?
Is there anything else that you would like Dr. Delpassand to know that you have not written about on any of these forms?
Signature and Date
I acknowledge that the information on this form is accurate to the best of my knowledge, and that I will inform Dr. Delpassand of any changes in my personal circumstances including, symptoms experienced, suicidal thoughts and substance use.

eSignature

PLEASE PRINT FORM BEFORE SUBMITTING

© 2018 by Dr. Nahal Delpassand