Richard I Jontry, Ph.D., MAC, CAC Diplomate
Licensed Psychologist
7 Hilloch Lane • Chadds Ford, PA, 19317
610-361-0108 [fax] 440-658-5759

CONFIDENTIAL CLIENT QUESTIONNAIRE

Please print the form, fill it in, and bring it with you on your next visit.
Thank you

It is also available as a PDF by
Clicking Here

Then come back to this page and
Please read the The Health Insurance Portability and Accountability Act
which addresses your right to privacy.

Your cooperation in completing this form will help in planning the most appropriate
services for you as well as providing me with information regarding your insurance.

Please answer each item carefully and ask for clarification if you do not
understand a question.

Name:                                                                  Date

Birthdate                                                             Gender

Address                                                              City

State                  Zip Code                     Home phone

Work phone

Email

Marital Status                                         Religion

Highest level of education completed

Occupation                                                                       Employer

Spouse's Occupation                                                      Employer

Highest level of education completed

Your Insurance Co.                                                           Plan Name

Name of Insured

Relationship to Insured                                                    Insured's SS#

Your SS#


Your Date of Birth                                                             Insured's Date of Birth

Your Insurance ID#                                                           Group#

Is precertification required?________


Family Physician                                                                         May I consult with your physician?

Physician's Phone

Psychiatrist (if applicable)                                                           May I consult with your psychiatrist?

Psychiatrist's Phone

How did you hear about this practice?

Describe briefly your reason for seeking help at this time:

Are you presently under a physician's care and/or on any medications?
please list:

List any family events over the last five years that have had a major impact on your life
(births, deaths, separations, divorces, moves, job change, etc.). Include dates.

Please indicate how often and how much of each of the following you use:

Caffeine (coffee, tea, soft drinks, chocolate)

Alcohol (Wine, beer, other)

Tobacco

Prescription, over-the-counter, and/or street drugs: (please identify).

We are all influenced by those closest to us. Please describe family members as well
as others who've been significant in your life, Include names, ages, deaths, mental or
physical health problems; drug or alcohol problems; emotional, physical or sexual abuse;
and your relationship with and feelings about the person.

Current mate.

Former mate (s)..

Children.

Mother.

Father.

Brothers/sisters

Grandparents.

Step or Foster parents.

Pets.

Any other person (friends, relatives, teachers, etc.) whom you feel may have played
significant roles in your life.

Please check any of the following problems that pertain to you:

Nervousness Depression Fears Shyness

Sleep Problems Suicidal Thoughts Separation Divorce

Finances Drug use Alcohol Use Friends

Anger Chronic Pain Unhappiness

Stress Work Relaxation Tiredness

Legal Matters Memory Ambition Energy

Decision Making Loneliness Inferiority Feelings Education

Concentration Career Health Problems Temper

Nightmares Marriage Children Parenting

Eating Disorder Weight Control Smoking Gambling

Are there other problems not listed above? Please describe.

Please add any additional information that you feet might be helpful.
Use reverse side if necessary.

In order to control your cost, we request payment at the conclusion of each visit.
Payment may be in the form of cash or check. Indemnity insurance reimburses
patients for fees already paid.
Some companies pay fixed allowances and others pay a percentage of the charge.
It is your responsibility to seek reimbursement from your carrier. I will be happy
to help you with the forms.

If unable to keep an appointment, Please give 24 hours notice. Otherwise,
you will be charged for the time reserved for you.

To the extent necessary to determine liability for payment or to obtain
reimbursement from my insurance company, I authorize disclosure of
portions of my records. I understand that disclosure
of such information will be the minimal required for such payment.
In the event Dr. Jontry applies for my insurance reimbursement because
I am unable to pay for my services at the time they are rendered,
I assign directly to him all medical benefits and authorize the use
of this signature for all insurance submissions.

Thank you for completing this questionnaire,

Please read the The Health Insurance Portability and Accountability Act
which addresses your right to privacy.

SIGNED                                                                                                   DATE

RESPONSIBLE PART (if minor)                                                           DATE


 

Thank you for taking the time to complete this form.