Patient Information Sheet

Contact Information:

info@drbarge.com

(310) 820-6300

Full Name

Date

Address where you

Phone Number

Email address

Okay to leave a message?

Yes

Date of Birth

Emergency Contact

Full Name / City, St / Contact Number

Physician Contact Information

Full Name / City, St / Contact Number

Medications

Please list all prescribed and over the counter medications

Insurance

Do you want claims filed?

Yes No

Have you been in therapy before or been on psychotropic medication?

Therapy

Psychotropic Medication

Explain

Are you experiencing overwhelming sadness, grief, or depression?

Sadness

Grief

Depression

How Long?

Do you have extreme anxiety or panic attacks?

Anxiety

Panic Attacks

How Long?

Have there been any sudden or recent changes in your life?

Yes No

Explain

Where did you grow up?

City

Suburbs

Country

Current Family

Married

Single

Divorced

Widowed

Other

Children

Full Name / Age / Sex

Family Origin

Do any of them have a history of mental illness, emotional problems or substance abuse/alcoholism?

Mother

Father

Sibling 1

Sibling 2

Sibling 3

How is your Health?

Excellent

Good

Just OK

Poor

Do you have sleep problems?

Yes No

Do you exercise?

Yes No

How Often?

Describe your use of:

Cigarettes

Drugs

Alcohol

What is your occupation?

Your information will be encrypted.

Dr. Joanne Barge, PhD

As an undergraduate studying psychology, I looked around and the therapists that I admired most had come from the counseling psychology program at USC. I worked hard to get into that graduate school. I was so excited when I was accepted and I loved every minute of it. It was truly a great training program at the time with some wonderful Professors. They warned us at the beginning to fasten our seat belts because it wasn’t going to be just book study.