Ascension Behavioral Health

Licensed Clinical Psychologist

Demographics & Self-Assessment Online Form

*Note: This form is only intended to be used after you have had a phone consult with Dr. Abrams and have both agreed upon and scheduled an initial intake appointment. Completion/submission of this form (online or hard copy) does not establish a treatment relationship with dr. abrams; This relationship is only established after your first appointment.

Today's Date
Today's Date
Name *
Name
Please enter the preferred name you would like to go by if different than above.
Date Of Birth *
Date Of Birth
Local Address *
Local Address
Phone (primary) *
Phone (primary)
Primary phone you would like to be contacted on.
Phone (secondary)
Phone (secondary)
Enter a secondary phone number you would like me to use if I can not reach you by the primary phone number you selected.
NOTE: Email is not a secure form of communication. Please be mindful of what you say about yourself and others in electronic communication.
Please provide your signature to indicate that Dr. Abrams can do so:
Spouse's Name
Spouse's Name
If utilizing insurance to assist with payment for services, please enter your insurance plan below.
Name of the person who referred you
Name of the person who referred you
If you answer "Yes," please complete the following question. If you answer "No," then disregard the following question.
If you answer "Yes," please complete the following question. If you answer "No," then disregard the following question.
If you answer "Yes," please complete the following question. If you answer "No," then disregard the following question.
If you answer "Yes," please complete the following question. If you answer "No," then disregard the following question.
Suicide *
Harm to Others *
How is your physical health at this time? *
Please describe your sleep habits by choosing an option below. *
Please describe your appetite by choosing an option below. *
If you answered other than "None," above, what time of day do you normally consume alcohol? *
Have you ever taken any of the following drugs? *
Please describe and include last use.
If this question does not apply to you, please write "Never."
Full Name