Dr. Astrid Heathcote, Licensed Clinical Psychologist

Married/Single/Divorced:

Number of Children/Step children:

Education: Highschool_____College:______Profession/Educational Training:

Developmental History (write in the space given if you have specific comments):
  -Typical
  -Concerns

 

  -Learning problems

 

  -Social problems (at school)
 

  -List specific concerns you may have regarding relationships, anxiety, depression, etc. and whether you have received treatment in the past.

  -List any medical treatments you have received in the past, including chronic medical conditions (e.g. diabetes), injuries, and/or surgeries.

  -Current and/or past use of drugs/alcohol.