New Client Questionnaire Notice: JavaScript is required for this content. Fields marked with an * are required HTML PERSONAL AND FAMILY INFORMATIONFOR JOHN R. FISHBEIN, PHD First Name * Last Name * Age * Email Address * Phone: Cell * Phone: Home Phone: Work Today's Date * Occupation * Home Address * City * US States * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip * Relationship Status * Single Married Separted Divorced Widowed If Married, How many years? If Separated, Divorced, or Widowed, What was the approximate year that this occurred? Spouse's First Name Spouse's Last Name Spouse's Age Spouse's Occupation Spouse's Cell Phone Name and ages of children. (Or, if living with your parents, names and ages of siblings.) If you are seeing a doctor, receiving medication or experiencing any physical symptoms (e.g., undue fatigue, headaches, stomach or sleep difficulties, etc.), please explain: If you or any immediate family member regularly consume alcohol or use non-prescription drugs, please explain: If you or any immediate family member do NOT eat three, well-balanced meals a day and get at least seven hours of sleep at night, please explain: How often do you get at least 30-minutes of cardiovascular exercises? What type of exercise? * What significant events have occurred in the last 2 years (death, child left home, move, job change, etc)? * Who referred you to this office? Would you permit Dr. Fishbein to discuss your case, if appropriate, with this person? * Yes No HTML Authorization for Release of Information I give permission for Dr. Fishbein to exchange information pertaining to my personal and/or family therapy with appropriate medical, legal and/or ecclesiastical individuals. * Self with Spouse with Parents If you are a human seeing this field, please leave it empty.