Registration

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Homayoun Shahri, Ph.D., M.A., CBT, MFT86676
4199 Campus Drive, Suite 550, Irvine, CA 92612

PLEASE COMPLETE THE FOLLOWING INFORMATION CLEARLY AND THOROUGHLY.
(You may also download this form, print it, fill it out, and bring it with you to the office - Download)

Registration

* Indicates required field

Date *

Name *

First

Last

Name of Person Completing the Form (if other than patient) *

First

Last

Name of Guardian (if applicable) *

First

Last

Date of Birth *

Marital Status *

Email *

Phone Number (Cell) *

Phone Number (Home) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Contact Person in Case of Emergency *

First

Last

Relationship to Patient *

Phone Number *

Primary Care Physician *

Current Medical Condition(s) *

Date of Last Exam *

Are you currently taking any medications? *

No Yes

If Yes, please identify the name, current dosage, and date began for each? *

Please describe the concerns that brought you here *

How long ago did they start? *

What have you done about this problem? *

Suicidal Thoughts/Ideations *

No Yes

Please answer whether or not you are experiencing any of the following symptoms:

Homicidal Thought/Ideations *

No Yes

Appetite Problems *

No Yes

Sleep Problems *

No Yes

Physical Problems *

No Yes

Anger/Irritability *

No Yes

Isolation/Social Widthrawal *

No Yes

Anxiety/Panic *

No Yes

Phobias *

No Yes

Binging/Purging *

No Yes

Poor Impulse Control *

No Yes

Violence Toward Others *

No Yes

Destruction of Property *

No Yes

Strange or Unusual Behavior *

No Yes

Confused or Irrational Thinking *

No Yes

Bothersome Repetitive Thoughts or Behaviors *

No Yes

Self Mutilation *

No Yes

Submit

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