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Margaret A. MacDevitt, Ph.D., P.C. 123 East Arch Street
Licensed Psychologist Marquette, MI 49855
Phone: (906) 226-9584
Fax: (906) 228-8057
Adult Initial Client Information Form
Client’s name: Date:
Gender: F M Date of birth: Age:
Form completed by (if someone other than client):
Address: City: State: Zip:
Phone (home): (work): ext:
If you need any more space for any of the questions please use the back of the sheet.
Primary reason(s) for seeking services:
Anger management Anxiety Coping Depression
Eating disorder Fear/phobias Mental confusion Sexual concerns
Sleeping problems Addictive behaviors Alcohol/drugs
Other mental health concerns (specify):
Family Information
Living Living with you
Relationship Name Age Yes No Yes No
Mother
Father
Spouse
Children
Significant others (brothers, sisters, grandparents, step-relatives, half-relatives. Please specify relationship.)
Living Living with you
Relationship Name Age Yes No Yes No
Marital Status (more than one answer may apply)
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Single Divorce in process Unmarried, living together
Length of time: Length of time:
Legally married Separated Divorced
Length of time: Length of time: Length of time:
Widowed Annulment
Length of time: Length of time: Total number of marriages:
Assessment of current relationship (if applicable): Good Fair Poor
Parental Information
Parents legally married Mother remarried: Number of times:
Parents have even been separated Father remarried: Number of times:
Parents ever divorced
Special circumstances (e.g., raised by person other than parents, information about spouse/children not living
with you, etc.):
Development
Are there special, unusual, or traumatic circumstances that affected your development? Yes No
If Yes, please describe:
Has there been history of child abuse? Yes No
If Yes, which type(s)? Sexual Physical Verbal
If Yes, the abuse was as a: Victim Perpetrator
Other childhood issues: Neglect Inadequate nutrition Other (please specify):
Comments re: childhood development:
Social Relationships
Check how you generally get along with other people: (check all that apply)
Affectionate Aggressive Avoidant Fight/argue often Follower
Friendly Leader Outgoing Shy/withdrawn Submissive
Other (specify):
Sexual orientation: Comments:
Sexual dysfunctions? Yes No
If Yes, describe:
Any current or history of being as sexual perpetrator? Yes No
If Yes, describe:
Cultural/Ethnic
To which cultural or ethnic group, if any, do you belong?
Are you experiencing any problems due to cultural or ethnic issues? Yes No
If Yes, describe:
Other cultural/ethnic information:
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Spiritual/Religious
How important to you are spiritual matters? Not Little Moderate Much
Are you affiliated with a spiritual or religious group? Yes No
If Yes, describe:
Were you raised within a spiritual or religious group? Yes No
If Yes, describe:
Would you like your spiritual/religious beliefs incorporated into the counseling? Yes No
If Yes, describe:
Legal
Current Status
Are you involved in any active cases (traffic, civil, criminal)? Yes No
If Yes, please describe and indicate the court and hearing/trial dates and charges:
Are you presently on probation or parole? Yes No
If Yes, please describe:
Past History
Traffic violations: Yes No DWI, DUI, etc.: Yes No
Criminal involvement: Yes No Civil involvement: Yes No
If you responded Yes to any of the above, please fill in the following information.
Charges Date Where (city) Results
Education
Fill in all that apply: Years of education: Currently enrolled in school? Yes No
High school grad/GED
Vocational: Number of years: Graduated: Yes No Major:
College: Number of years: Graduated: Yes No Major:
Graduate: Number of years: Graduated: Yes No Major:
Other training:
Special circumstances (e.g., learning disabilities, gifted):
Employment
Begin with most recent job, list job history:
Employer Dates Title Reason left the job How often miss work?
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Currently: FT PT Temp Laid-off Disabled Retired
Social Security Student Other (describe):
Military
Military experience? Yes No Combat experience? Yes No
Where:
Branch: Discharge date:
Date drafted: Type of discharge:
Date enlisted: Rank at discharge:
Leisure/Recreational
Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor
activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.)
Activity How often now? How often in the past?
Medical/Physical Health
AIDS Dizziness Nose bleeds
Alcoholism Drug abuse Pneumonia
Abdominal pain Epilepsy Rheumatic Fever
Abortion Ear infections Sexually transmitted diseases
Allergies Eating problems Sleeping disorders
Anemia Fainting Sore throat
Appendicitis Fatigue Scarlet Fever
Arthritis Frequent urination Sinusitis
Asthma Headaches Small Pox
Bronchitis Hearing problems Stroke
Bed wetting Hepatitis Sexual problems
Cancer High blood pressure Tonsillitis
Chest pain Kidney problems Tuberculosis
Chronic pain Measles Toothache
Colds/Coughs Mononucleosis Thyroid problems
Constipation Mumps Vision problems
Chicken Pox Menstrual pain Vomiting
Dental problems Miscarriages Whooping cough
Diabetes Neurological disorders Other (describe):
Diarrhea Nausea
List any current health concerns:
List any recent health or physical changes:
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Nutrition
Meal How often Typical foods eaten Typical amount eaten
(times per week)
Breakfast / week No Low Med High
Lunch / week No Low Med High
Dinner / week No Low Med High
Snacks / week No Low Med High
Comments:
Current prescribed medications Dose Dates Purpose Side effects
Current over-the-counter meds Dose Dates Purpose Side effects
Are you allergic to any medications or drugs? Yes No
If Yes, describe:
Date Reason Results
Last physical exam
Last doctor’s visit
Last dental exam
Most recent surgery
Other surgery
Upcoming surgery
Name of Physician(s): __________________________________________________________
Family history of medical problems:
Pleases check if there have been any recent changes in the following:
Sleep patterns Eating patterns Behavior Energy level
Physical activity level General disposition Weight Nervousness/tension
Describe changes in areas in which you checked above:
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Chemical Use History
Method of Frequency Age of Age of Used in last Used in last
use and amount of use first use last use 48 hours 30 days
Yes No Yes No
Alcohol
Barbiturates
Valium/Librium
Cocaine/Crack
Heroin/Opiates
Marijuana
PCP/LSD/Mescaline
Inhalants
Caffeine
Nicotine
Over the counter
Prescription drugs
Other drugs
Substance of preference
1. 3.
2. 4.
Substance Abuse Questions
Describe when and where you typically uses substances:
Describe any changes in your use patterns:
Describe how your use has affected your family or friends (include their perceptions of your use):
Reason(s) for use:
Addicted Build confidence Escape Self-medication
Socialization Taste Other (specify):
How do you believe your substance use affects your life?
Who or what has helped you in stopping or limiting your use?
Does/Has someone in your family present/past have/had a problem with drugs or alcohol?
Yes No If Yes, describe:
Have you had withdrawal symptoms when trying to stop using drugs or alcohol? Yes No
If Yes, describe:
Have you had adverse reactions or overdose to drugs or alcohol? (describe):
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Does your body temperature change when you drink? Yes No
If Yes, describe:
Have drugs or alcohol created a problem for your job? Yes No
If Yes, describe:
Counseling/Prior Treatment History
Information about client (past and present):
Your reaction
Yes No When Where to overall experience
Counseling/Psychiatric
treatment
Suicidal thoughts/attempts
Drug/alcohol treatment
Hospitalizations
Involvement with self-help
groups (e.g., AA, Al-Anon,
NA, Overeaters Anonymous)
Information about family/significant others (past and present):
Your reaction
Yes No When Where to overall experience
Counseling/Psychiatric
treatment
Suicidal thoughts/attempts
Drug/alcohol treatment
Hospitalizations
Involvement with self-help
groups (e.g., AA, Al-Anon,
NA, Overeaters Anonymous)
Please check behaviors and symptoms that occur to you more often than you would like them to take place:
Aggression Elevated mood Phobias/fears
Alcohol dependence Fatigue Recurring thoughts
Anger Gambling Sexual addiction
Antisocial behavior Hallucinations Sexual difficulties
Anxiety Heart palpitations Sick often
Avoiding people High blood pressure Sleeping problems
Chest pain Hopelessness Speech problems
Cyber addiction Impulsivity Suicidal thoughts
Depression Irritability Thoughts disorganized
Disorientation Judgment errors Trembling
Distractibility Loneliness Withdrawing
Dizziness Memory impairment Worrying
Drug dependence Mood shifts Other (specify):
Eating disorder Panic attacks
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Briefly discuss how the above symptoms impair your ability to function effectively:
Any additional information that would assist us in understanding your concerns or problems:
What are your goals for therapy?
Do you feel suicidal at this time? Yes No
If Yes, explain:
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Diag: ________________
(To be completed by Dr. MacDevitt)
PATIENT INSURANCE INFORMATION
Full Name:_________________________________________Today’sDate:_____________________
Address___________________________________________________________________________
Street City State Zip
Phone number:________________Work phone:________________ Date of Birth:_____/____/______
Gender: M F Age: _________Source of referral:________________________________________
Employer: ___________________________________Social Security #: ________________________
PrimaryInsuranceCompany:___________________________________________________________
Insur CoAddress:__________________________________________________________________
Street City State Zip
Insur Co. Telephone:________________________________________
Policy holder:__________________________________ Policy#:_____________________________
Employer/Group #_______________________________SS #:________________________________
Patient’s relationship to Policy Holder:_______________ Policy Holder Date of Birth: ___/____/____
If there is other (Secondary Insurance) please complete the following:
Secondary Insurance Company:________________________________________________________
Address:___________________________________________________________________________
Street City State Zip
Telephone: ______________________________________________
Policy Holder:_______________________________Policy #:________________________________
Employer/Group #:___________________________ SS#:___________________________________
Patient’s relationship to Policy Holder:____________Policy Holder Date of Birth:_____/____/______
***********************************************************************************
IMPORTANT THAT YOU SIGN BELOW IF YOU WANT US TO BILL YOUR
INSURANCE
RELEASE
I certify the information given by me regarding my insurance plans is correct to the best of my knowledge. I
authorize release of all records required and request payment of authorized benefits be made in my behalf to Dr.
MacDevitt. I understand that in the case of payment made at the time of service, insurance payments will be made
directly to me or to the responsible party as appropriate.
Authorized Signature:______________________________________________________
Relationship to patient:_____________________________________________________
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Agreement Regarding Appointments and Fees
I understand that I am requesting psychotherapy, counseling and related services from Margaret A. MacDevitt,
Ph.D. and that such services will be provided under the terms of the following agreement. In particular, I
acknowledge that all charges accruing from such services are to be paid my me according to this agreement.
As used in the Agreement, “Psychologist” is Margaret A. MacDevitt, Ph.D.,P.C., as above and I am identified as
the “Client”. My name, address, and telephone number are as listed below. Although I am identified as the
“Client”, I may not be the person receiving services directly for the Psychologist; however, I agree that I am the
person financially responsible for all charges for such services.
APPOINTMENTS: normally an individual, couple, or family is seen for a 50 minute session at a time. These
sessions are scheduled at a frequency (usually once per week) which is mutually determined by the Client and
Psychologist with regard to their mutual needs and available time.
FEES: Psychotherapy and counseling sessions are often partially covered by insurance (BlueCross,
Champus, and many others). The fees for treatment are listed on the attached schedule, which is incorporated as
part of this agreement. PERSONS FOR WHOM THE FEE REPRESENTS AN OBSTACLE TO
TREATMENT ARE ENCOURAGED TO DISCUSS THIS WITH THE PSYCHOLOGIST.
INSURANCE: The Psychologist contracts with a billing service to file Insurance claims for you, but
assumes no liability or responsibility in doing so. Client understands that Client is responsible for all charges
regardless of the actions of Client’s insurance carrier, and any assistance by the Psychologist to help the Client
obtain benefits in no way constitutes a waiver by the Psychologist of any portion of the fees charged.
If any action is brought to enforce this agreement, the Psychologist shall be entitled to its attorney’s fees and
costs if it is the prevailing party; in addition, the Psychologist shall be entitled to reimbursement for its
reasonable expenses in attempting to collect unpaid fees.
PAYMENT PLAN: Fees are payable at time of service rendered unless otherwise arranged and may be
paid by check or cash. Alternative payment arrangements should be discussed during your first visit.
UNKEPT APPOINTMENTS: cancellation of appointment must be made 24 hours in advance of the time
of the appointment. Failure to keep an appointment or cancellation of an appointment less than 24 hour in
advance will result in the Client being charged unless the appointment time is used by another Client who could
not otherwise have been accommodated.
TERMINATION OF SERVICES: The Client may terminate the services of the Psychologist at any time,
subject to the above requirement to cancel appointments. The Psychologist retains the right to terminate any
obligation to the Client to provide continuing treatment by giving the Client (7) days notice of intent to do so.
The Psychologist may also elect to refer the Client to such professionals as the Psychologist, in her discretion,
sees fit.
The Psychologist shall have no other obligations to the Client and the Psychologist’s professional liability shall be
limited to any acts which depart from usual professional practices where acceptable standards are not followed
and due care not exercised.
DATED:_________________________________ __________________________________________
Client Signature
BY:_____________________________________ _________________________________________
Psychologist Person Responsible for Payment
Margaret A. MacDevitt, Ph.D.
_________________________________________
Address
_________________________________________
Telephone #
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A copy of “The Notice of Privacy Policies and Practices” for Margaret A. MacDevitt, Ph.D. is available on this web
site and is also located on top of the waiting room bookcase (next to the coffee pot) for your review. If you
would like to have a copy of that, please download one from this web site or ask Dr. MacDevitt during your
session with her.
Please sign below indicating that you have been given the opportunity to read the “Privacy Policy”:
Patient/Representative:__________________________________________________
Date:________________________________
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Margaret A. MacDevitt, Ph.D., P.C.___________________________________________
Licensed Psychologist 123 East Arch Street
Marquette, Michigan 49855
(906) 226-9584
Fees For Services Rendered
Initial Diagnostic Interview (50 minutes)………………………………………...$200.00
Psychotherapy, Individual (50 minutes)…………………………………………. $125.00
Psychotherapy, Couple/Family (50 minutes)…………………………………….. $150.00
Late Cancellation or No Show…………...………………………………………. $125.00
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