Personal Information

Bellagio Psychotherapeutics – Dr. Mark Zuccolo

Date

First Name *

Last Name *

Email Address *

Street Address *

Apartment, suite, etc.

City *

State *

ZIP / Postal Code *

Cell Phone *

May we leave a voice mail on your cell phone? *YesNo

Home Phone

May we leave a voice mail on your home phone?YesNo

Preferred appointment reminder *Email me the appointment reminder the day beforeText me the appointment reminder the day before

Your Age *

Birthdate *

Who lives with you? *Spouse or significant otherFamily of originFriend or roommate(s)I live alone

Emergency contact person *

Emergency Contact Phone *

Briefly describe the issue you need to discuss *

On a scale of 0-10 how distressed are you by this issue? *0=not at all - 10=Extremely

On a scale of 0-10 how well are you functioning in life? *0=not at all - 10=Very well

Medical or mental conditionsIllness(es) or disorder(s) for which you're being treated by a physician or psychiatrist

Current medicationsMedications prescribed by a physician or psychiatrist

Childhood environmentChildhood Environment & Sibling Position (e.g., 2 biological parents, blended stepfamily, adopted; oldest child, middle child)

Spiritual beliefse.g., spiritual, religious, in ministry, none

Have you had counseling before? *Individual counselingCouples counselingFamily counselingNever

How did you hear about us? *