General Info Form - Joy A. Dryer Ph.D

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JOY A. DRYER Ph.D

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Types of Help
Forms
Resources
Meet Dr. Joy
For Professionals
Contact

General Registration

"*" indicates required fields

I. BASIC INFORMATION

Hidden

Type

Individual

Couples

Mediation

Today's Date

MM slash DD slash YYYY

Name*

Birthday*

MM slash DD slash YYYY

Age

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Work Phone

Prefer to be called on which number?

Email*

Who (other than children) lives at this address? Give names & relationship. Can a message be left with them? Y / N

Employer

Occupation

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Hours

Education (highest level completed)

Are you currently in school?

Yes

No

What are you studying?

Degrees

Source of Referral: Who referred you to me?

II. FAMILY INFORMATION

A. Family:

Mother Alive?

Yes

No

Year Mother Died

Mother's Birth Place

Father Alive?

Yes

No

Year Father Died

Father's Birth Place

Parent's Live together?

Yes

No

Siblings: Names/Ages:

Do any family members have a history of psychological problems?

Yes

No

If so, please describe

Do any family members have a history of medical problems?

Yes

No

If so, please describe

B. Information About CHILDREN

List Name of each Child ,M/F, Date of Birth, Age, Grade Level, Where Resides

(Use new line for each child)

Are there any speciﬁc health/educational/mental health requirements for any of these children? For Whom? What?

III. PERSONAL INFORMATION

How long have you been in relationship (in years if applicable)

Partner's Name

If there are unusual circumstances relevant to your relationship, please describe:

Have you been hospitalized for medical reasons?

Yes

No

Describe medical reasons

Have you been hospitalized for psychological reasons?

Yes

No

Describe psychological reasons

Have you ever had any physical or mental illness, signiﬁcant health problem or serious accidents that affected you for an extended period of time (more than a year)?

Yes

No

If so, please indicate type/ dates/ and current status.

Your health in childhood was generally:

Excellent

Good

Fair

Poor

At present your health is generally:

Excellent

Good

Fair

Poor

When was your last physical?

How often do you exercise?

How often do you meditate?

List medications (including vitamins, aspirin, sleeping pills, etc.) during last 2 years:

If you are currently in any type of therapy or counseling, what kind?

With whom are you in therapy or counseling?

For how long?

Will you give me written permission to speak to your current therapist?

Yes

No

Have you had any history of physical or sexual abuse?

Yes

No

By Whom?

Have you needed to cut back on drinking or drug use?

Yes

No

If so, when?

What substance(s)?

IV. FINANCIAL INFORMATION

Pre-Covid19, what was your approximate Gross income?

Net income?

Current Approximate Gross?

Current Net?

Partner's Net?

Changes in income in the last two years?

Yes

No

And, or expected in next 2 years?

Yes

No

Please explain

Financial concerns you have i should know about?

V. MAJOR LIFE EVENTS or CHANGES

Check all that apply

Started school or training program

Child(ren) born

Fertility problem(s)

Changed job

Lost job

Moved residence

Financial troubles

Increase in ﬁnancial responsibilities

Legal problems

Separation/divorce of friend/relative

Health problems for yourseld

Health problems for your patner

Health problems for your child(ren)

Death of a close friend.

Death of family member

Death of household pet

Pregnancy, wanted/not wanted

Grandchild born

Miscarriage

Graduated from school/program

Changes in childcare

Trouble with Children?

Onset of menopause

Midlife crisis

Victim of a crime

Undertaken a major new expense

Natural disaster

Child left for college

Child marrying

Anyone added to household

Began treatment for drug/ alcohol problem

Began psychotherapy

Began new medication

Signiﬁcant weight gain/loss

VI. Emergency Contact:

Emergency Contact Name

Emergency Contact Email

Emergency Contact Cell Phone

Emergency Contact Relationship to you

Insurance Company Name

Who's name is your insurance under?

Yours

Your partners

Isnsurance Phone #

Member #

VII. Your Thoughts:

Please describe brieﬂy why you are seeking professional help? Why now?

What concern(s) do you have for yourself?

For others?

Anything else I should know?

Comments? Questions?

New York City Office

92 Remsen St. Suite 1A

Brooklyn Heights NY 11201

Zoom and in-person sessions available

Please note: No insurance accepted only Out-of-Network (OON) benefits

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