Client Information

Client Information

Address

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Referral Source

Therapy Focus

Medical History

Are you under a doctor's care?

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Are you taking any medication?

Have you ever been hospitalized for physical illness?

Mental Health History

Have you previously received therapy/counseling?

Have you ever been hospitalized for mental illness? (mood disorder, suicidal ideation, etc)

Health Conditions

Substance History

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

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Dr. Leslie Davis, MFT

Lic. #LMFT 43044

1777 N. Bellflower Blvd, Suite #205 Long Beach CA 90815

866-824-4132

doctorlesliedavis.com

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