California Psychological Institute
1470 West Herndon Avenue
Fresno, CA 93711
Do you have health Insurance Information for mental health services?
Please list all medications you are currently taking, including over-the-counter and herbal.
Have you had past Counseling or Psychotherapy? If yes, please respond below:
Have you had any psychiatric hospital admissions?
Have you previously received, or are you currently receiving any additional services? Ex: TBS, IEP, Wrap services, EPU etc:
Thank you for your cooperation. This information will be helpful in planning services for you. All information on this form is confidential and will not be released without your prior written approval.
Responsible Party :______________________________________________________________
Please print out this page after you have filled it out, then sign it and bring it with you on your first visit.