Ingrid Oliansky, Licensed Marriage and Family Therapist
​MFC# 48975
Call for an appointment (818) 927-3855
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Psychiatric and Medical History
Dates of any previous therapy:
Do you drink alcohol or take any recreational drugs?
If yes, please explain:
Have you ever experienced any of the following?:
Hallucinations? Visual or Audio?
If Yes
Eating Problems
Sleeping Problems
Suicidal Thoughts
Suicide Attempts
If yes to any of the above, Please explain:
Client Name:
Do you have any medical conditions?
If you answered "Yes", please explain:
YesNo
VisualAudio
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo