Reason For Visit Form

Please correct the errors described below.

Mark D. Ackerman, Ph.D. Licensed Psychologist

2751 Buford Highway Suite #410 Atlanta, GA 30324

Telephone: 770-396-2206
E-Mail Address: DrMark@clinicalforensicpsychsvs.com
Website: ClinicalForensicPsychSvs.com

Please select any of the following areas of concern, either past or present:

Alcohol/Drug Abuse

Obsessive Thoughts

Phobias

Attention/Concentration

Insomnia

Self-Injurious Behaviors

Dissociation

Domestic Violence

Medical Concerns

Work Problems

Sexual Concerns

Hopelessness

Parenting Concerns

Assertiveness

Impulse Control Problems

Self-Esteem Issues

Depression

Legal Issues

Marital/ Relationship Problems

Suicidal Thoughts

Hallucinations (seeing or hearing things)

Delusions (implausible beliefs)

Paranoia

Anxiety

Isolation

Bereavement/Grief

Communication

Identity Issues

Sexuality

Stress

Memory

Panic Attacks

Anger Control

Hostility

School Problems

Self-Defeating Behaviors

Excessive Irritability

Sexual Abuse

Spirituality

Eating/Food Issues

Family Problems

Excessive Worrying

Other Concerns

Medical Problems

Primary Physician

Date of Last Visit

Have you been in counseling or therapy before?

Yes No

Date

Nature of Problem

Therapist

Benefit from therapy?

Current medications:

Medication

Dosage

Reason for Use

Prescribing Physician

Please describe use of alcohol or other substances:

Substance

Substance Frequency of Use

Please list anyone in your family who has been in therapy or diagnosed with any type of mental illness:

Relationship to You

Problem

Nature of Treatment, if any

Is there anything else you would like me to know?

E-Signature

Date

Your information will be encrypted.

Mark D. Ackerman, Ph.D. Licensed Psychologist

2751 Buford Highway Suite #410 Atlanta, GA 30324

Telephone: 770-396-2206
E-Mail Address: DrMark@clinicalforensicpsychsvs.com
Website: ClinicalForensicPsychSvs.com

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