Brian Matthews, L.M.F.T.Professional CorporationLicense #: 5108NPI: 11645708754425 South MO-PAC ExpresswayBuilding IV, Suite 700Austin, Texas 78735(Tax ID: 20-5603420)Telephone: 512.314.5551 BIOGRAPHICAL INFORMATION-INTAKE FORMPlease fill out this biographical background form as completely as possible (use additional sheets of paper where necessary). It will help me in our work together. All information is confidential as outlined in the Office Policy form. If you do not desire to answer any question, merely write Do not care to answer. Please print or write clearly and bring it with you to the first session.NAME: _ MALE/FEMALE: _ DATE: _DATE OF BIRTH/PLACE: _ AGE: _ADDRESS: _ _ TELEPHONE: H: _ W: _ CELL: _FAX: _ EMAIL: _HIGHEST GRADE/DEGREE: _ TYPE OF DEGREE: _ PERSON(S) AND PHONE NUMBERS TO CALL IN EMERGENCY: _ _REFERRAL SOURCE: _OCCUPATION (former. if retired): _PRESENTING PROBLEM (be as specific as you can: When did it start, how does it affect you): _Estimate the severity of the above problem: Mild_ Moderate _Severe _Very severe _CURRENT: Marital status: _ Live with someone: _ Name: _ Yrs: _PAST & PRESENT MARRIAGE/S (years together, names & statement about the nature of the relationship/s, i.e., friendly, distant, physically/emotionally abusive, loving, hostile): _PRESENT SPOUSE/PARTNER: Education: _ Occupation: _CHILDREN/STEP/GRAND (names/ages & brief statement on your relationship with the person) 1._2._3._4._5._PARENTS/STEP-PARENT (Name/age or year of death/cause of death, occupation, personality, how did s/he treat you, brief statement about the relationship): Father:_Mother:_Stepparents_SIBLINGS (name/age, if dead: age and cause of death & brief statement about the relationship): 1._2._3._4._5._MEDICAL DOCTOR/S (name /phone): _ _PAST/PRESENT MEDICAL CARE (major medical problems, surgeries, accidents, falls, illness): _