Eileen Keller Ph.D. - Initial Information Form

L. Eileen Keller, Ph.D.
5435 College Avenue, Suite 201
Oakland, California 94618

Licensed Psychologist, PSY7350
(510) 654-2420

INITIAL INFORMATION FORM - CHILD

Date:
Child's name:

Parents marital status:

Child's Date of Birth:

Custody:

Mother's name:

Address:

Phone, Work:

Phone, Home:

Cell Phone:

Occupation:

Age:

Messages ok?

Father's name:
Address:

Phone, Work:

Phone, Home:

Cell Phone:

Occupation:

Age:

Messages ok?

Siblings:

Other caretakers:

Prior therapy:

Emergency Contact:

Please tell me what worries you have about your child.