Advanced Behavioral Health Counseling

Specializing in Group, Individual, Coaching and Marital Therapy

Office Forms

You can also send your information to my office by registering with a site called Patient ally. If interested click the link below.

http://www.patientally.com

Advanced Behavioral Health

Sylvia Ybarra, M.A., M.F.T.

27349 Jefferson Ave. Suite 205

Temecula, CA.  92590

951 852-1870

 

Please print and bring to your appt.  Thank-you

 

Welcome

I am happy to have you as a client and will do everything in my professional capacity to provide you with the best possible mental health care.

 

Patient:  _________________________________________  Age: ________           Sex:  M    F

 

Address: ________________________________________________________________________

 

DL:      ___________________________________ e-mail __________________________________

 

Phone:   (______)________________ Cell: (______) ____________Date of Birth: ____/_____/_____

 

SS#:       ______-____-_______    Emergency Contact & #: __________________________________

 

Responsible Person:  (Note: If this information is same as patient, write “same as above”)

Name:    _____________________________________ Relationship:  _______________

 

Address:   _______________________________________________________________

 

                 _______________________________________________________________

 

Phone:   (_______)_____________________

 

Insurance Information:

Insurance Company:  ________________________________ Phone: ______________________

 

Patient’s ID #  ________________________________    Group #: ________________________

 

Subscriber’s Name & Address:  ____________________________________________________

 

                                    ____________________________________________________________ 

 

Subscriber’s SS#:  _____________________________ Subscriber’s DOB: _________________

 

Subscriber’s Employer’s Name: ____________________________________________________

 

Subscriber’s Relationship to Patient:  _______________________

 

Secondary Insurance? _____________________________________________________________

 

Are you in any legal proceedings, workers compensation or disability presently or expect to be within the next year?

 

_______________________________________________________________________________

 

Consent for Treatment:

I consent to assessment, treatment, and/or diagnostic procedures for myself or for my family member.  I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement.  I authorize the release and exchange of information between my therapist and the referral source and other co-treating providers for the purpose of treatment, payment, and Health Care Operations.  I also authorize the release of information to my health plan for claims or other health plan purposes.

__________________________________________________             ______________

Patient/Legal Representative Signature                                                   Date

 

 

Clients Name:_____________________________

 

 Please rate the severity of the following symptoms over the last month according to the following rating scale:               

0-No difficulty

1-Mild

2-Moderate

3-Severe

 

_____ Decreased appetite                                           _____ Nightmares

_____ Increased appetite/eating more                        _____ Hypervigilance

_____ Bingeing and/or purging                                  _____ Obsessive thoughts

_____ Weight change? +/- _____ lbs.                        _____ Compulsions

_____ Depressed mood                                              _____ Spending sprees

_____ Decreased energy/fatigue                                _____ Racing thoughts

_____ Sleep changes: trouble falling asleep;              _____ Rapid heart beat

                 trouble staying asleep; trouble                   _____ Trouble breathing

                 waking up                                                  _____ Sweating

                 Avg. # hours sleep _____                          _____ Phobia

_____ Decreased sexual desire                                   _____ Police/Probation involvement

_____ Difficulty with sexual functioning                  _____ Stealing

_____ Loss of interest in activities                             _____ Lying

_____ Crying                                                              _____ Truancy

_____ Feelings of hopelessness                                  _____ Violent behavior towards

_____ Feelings of helplessness                                                           others

_____ Decreased attention span                                 _____ Destruction of property

_____ Inattentive/Distractible                                                _____ Harming animals

_____ Memory problems: Long-term;                        _____ Fire setting

                        short-term                                            _____ Opposition

_____ Self-injurious behavior                                     _____ Anger outbursts

_____ Thoughts of suicide                                         _____ Irritability

_____ Thoughts of harming others

_____ Impulsivity

_____ Hyperactivity

_____ Anxiety/Nervousness

_____ Worry/Fear

_____ Flashbacks of traumatic event

 

 

 

 

Patient’s Name ___________________________________________________________

 

 

How many alcoholic beverages do you consume per week? _______

 

List street drugs used in last 2 months (type/frequency/amount): ____________________

 

________________________________________________________________________

 

Family history of substance abuse problems? ___________________________________

 

________________________________________________________________________

 

 

Previous psychological or psychiatric treatment? (List dates & provider names): _______

 

________________________________________________________________________

 

________________________________________________________________________

 

Any psychiatric hospitalizations? ____________________________________________

 

________________________________________________________________________

 

Medical history: __________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

Current medications