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David Bloodgood, Ph,D.
1850 Lee Rd. Suite 103
Winter Park, Fl. 32789
REGISTRATION FOR NEW PATIENTS
Each session lasts 50 minutes. Patients may wish to provide the following information before their first session to allow more time for therapy in their initial session.
Please print his form and bring it with you to your first visit
PATIENT’S NAME _______________________
ADDRESS ___________________________________________________________________________
CITY AND STATE _____________________________________ ZIP CODE _______________
HOME PHONE ____________________ WORK PHONE ______________________
CELL PHONE OR PAGER ___________________________
SOCIAL SECURITY # _____________________________________
(Answer the following questions)
1.The primary reason I am seeking therapy at this time is:
2. Discuss and evaluate any previous experiences you have had with therapy:
3. Briefly outline your expectations for this therapeutic experience. What do you want
to happen as a result of your work in therapy:
Telephone: (407) 246-1556 | e-mail: dr@bloodgood.com