Client Information

Address

Country

State/Province

Referral Source

Presenting Problem

Medical History

Are you under a Doctor's care?

Are you taking any medication

Have you ever been hospitalized for physical illness?

Health Conditions

Mental Health History

Have you previously received therapy/counseling?

Have you ever been hospitalized for Mental Illness? (Mood Disorder, Suicidal Ideation, etc)

Substance History

Legal History

Have you ever been arrested, charged, and/or convicted of a crime?

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Melissa Paramo, LMFT Therapy

Lic. # LMFT 51549

4101 McGowen St, STE 110 #332, Long Beach CA 90808

714-624-4294

ParamoTherapy@gmail.com

www.TherapistMelissa.com

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