Dr. Stacy Berlin

Full name

Age and Date of Birth

Email

Cell phone

Work phone

In case of emergency call

Emergency phone

Home Street Address

Home City and Zip

Employer and position

Work Street Address

Work City and Zip

Referring party (referring party will not be contacted)

List all medications, dosages, and for what

Reason(s) for seeking therapy

Please check all that apply

Have you been hospitalized for an emotional problem?
Have you ever attempted suicide?
Have you ever tried to hurt yourself in other ways?
Have you ever tried to physically hurt someone else?
Have you ever been involved in criminal activity?
Have you ever been involved in physical fights?