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Client Information

Heidrich Psychological Evaluations Center and Psychotherapy
270 26th St. Suite 201. Santa Monica, CA. 90405
5743 Corsa Ave. Ste 125. Westlake Village, CA. 91360
Brenda Heidrich | Ph.D Lic# Psy 29105 | Phone: 310-748-8393

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Personal Information

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Medical and Health History

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Primary Care Physician:

Address

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Date of your most recent physical examination:

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Please list all current medications and dosages:

Name of Medication / Dosage / Name of Prescribing Doctor / When did you start taking it?

List all therapists you have seen, and dates you saw them:

Please indicate which of these substances you currently use(Required)

Cigarettes

Alcohol

Pills not prescribed for me

Marijuana

Cocaine or crack

LSD

Heroin

None of the above

How often?

What kind of problem brings you the see Therapy?

Type of Incident(Required)

Auto

Dog Bite

Fall

Other

Incident Type(Required)

Referred By(Required)

Doctor

Lawyer

Referred By Name(Required)

When did Incident Occur?(Required)

Pain on scale 1-10 episodic(Required)

Pain on scale 1-10 constant(Required)

Medication being taken for incident pain(Required)

Body parts affected by incident?(Required)

Type of procedure expected(Required)

SCS (spinal cord stimulator) Implant

SCS (spinal cord stimulator) Trial

Gastric Bypass

Post-Accident-Incident Evaluation

Peripheral Nerve Stimulator

Other

None

Other type of procedure expected(Required)

Please indicate if you are having any of the following problems, or if you had them in the past

Depression

Anxiety

Difficulty falling asleep or staying asleep

Sleeping too much

Change in appetite, weight loss, or weight gain

Frequent crying

Panic attacks or anxiety attacks

Thoughts of killing or hurting myself

Attempts to kill or hurt myself

Problems concentrating

Problems remembering things

Periods of daily sadness lasting more than two weeks

I startle easily

Can’t stop remembering upsetting past events

Difficulty controlling my temper

I physically hurt other people

I break things sometimes

I worry a lot

Little or no interest in sex

I feel tired almost every day

Feelings of unreality

Made myself throw up in order to lose weight

Used laxatives or exercised excessively to lose weight

I often feel like I am an outsider

Sexual problems

Worry that something is wrong with my body

Frequent arguments with the people I live with

I hear voices inside my head

None of the above

Other (please list):

Do you have any physical pain?

Head

Neck

Face

Upper back

Mid back

Lower back

Shoulders

Arms

Hands

Chest

Legs

Knees

Feet

Agreement & Submission

Dear Client:
Please understand that any sessions missed after having been confirmed at least 48 hours in advance will be charged against the Lien.

Signature(Required)

I agree to the terms and conditions and privacy policy.

Client Consent | Medical release | HIPAA

HIPAA Acknowledgement(Required)

By checking this box you indicate that you have been presented the privacy form(HIPAA) or if said patient is under 18 you are guardian and said patient has received the privacy form.

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We pride ourselves on quick turnaround

Contact

Call us to schedule an appointment
Dr. Goodman: +1 -818-917-4524
Dr. Heidrich: +1-310-748-8393 ,
or
send us an email and we will get back to you
as soon as possible.