BRIAN NEVILLE, Ph.D.

Client Information
Today’s Date ________________________ Date of birth _______________________________

Name ____________________________________________ Age _____ Gender: ”Male ”Female

Address _____________________________________________________________________________________
Street City ST Zip

Phones Home____________________ Work ____________________ Cell ________________________

Who referred you to this clinic? _________________________________________________________________________

Address _____________________________________________________________________________________

Client’s physician ___________________________________ Phone _____________________________________

Address _____________________________________________________________________________________

Emergency contact ____________________________ _______________________ ____________________________

Name Phone Relation to client

Employer/School ______________________________________ Position/Grade____________________________________

Is client on any medications? Yes / No If yes, name and dosage _______________________________________________

Describe any chronic medical or developmental problems

Previous psychological evaluation or treatment (provider, date and type):

Describe any learning or academic problems

If Client is a minor

Mother’s Name _________________________________ Age _____ Date of birth _________________________

Address ______________________________________________________________________________________

Phones Home_________________ Work ____________________ Cell _________________________

Employer ______________________________________ Position ______________________________________

Father’s Name _________________________________ Age _____ Date of birth _________________________

Address ______________________________________________________________________________________

Phones Home_________________ Work ____________________ Cell _________________________

Employer ______________________________________ Position ______________________________________

Client Inform ation 1

BRIAN NEVILLE, Ph.D.

Insurance Information
I strongly encourage you to verify your mental health coverage since it varies from plan to plan and is
generally covered at different rates from other medical conditions. Many insurance companies also require
preauthorization for mental health benefits. If I am a contracted provider with your insurance company, I
will file the insurance claim for you and will only expect your co-payment at the time of service. Privately
insured clients are required to pay in-full at the time of their appointment and to handle all paperwork in
seeking reimbursement from their insurance company. The bill which I will give you contains the necessary
information for most companies. Please remember that you are solely responsible for paying, regardless of
the insurance company’s actions.

Policy holder’s name: ___________________________

Insurance Company Name: ___________________________

Plan Name: ___________________________

Subscriber ID number: ___________________________

Group number: ___________________________

Policy number: ___________________________

Are preauthorizations required? Yes / No

Number of visits authorized: ____

Mailing address for claims: ___________________________________________________________

Street City ST Zip
I give my permission for information to be released to my insurance company for the purpose of filing
claims.

______________________________ ______________
Signature Date

Client Inform ation 2

 Current Concerns
Please briefly describe current concerns in any of the following areas:

Behavior problems

Learning or Memory Problems

Communication

Ability to relate to others

Attention or activity level

Substance Abuse

Unusual thoughts or beliefs

Mood problems

Anxiety problems

Recurrent pain or physical problems

Sleeping problems

Eating problems

Other (describe)

Client Inform ation 3

 Medical History
Please list history of significant medical problems
9 asthma 9 fine motor or handwriting problems
9 allergies 9 sleep problems,
9 diabetes 9 appetite problems,
9 epilepsy or seizures 9 bowel and bladder control problems,
9 lead poisoning 9 speech or language problems,
9 chronic ear infections 9 high fevers (over 103)
9 eye or vision problems 9 head injuries
9 hearing problems 9 surgery
9 gross and fine motor problem s, clumsiness 9 other illnesses (specify)
9 other injuries or accidents (specify):

Currently being treated for:

Currently on following medications:

Is there a history in the family of:

9 physical abuse
9 sexual abuse
9 alcohol abuse
9 drug abuse

Family History

Mother Father

Highest grade completed

Learning problems

Behavior or mental health problems

Chronic medical problems

List of blood relatives with learning or Name: Name:

mental health problems Relation Relation
Condition Condition

Name: Name:
Relation Relation
Condition Condition

Nam e: Nam e:
Relation Relation
Condition Condition

Client Inform ation 4

Client Inform ation 5