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Dr. Beth O'Brien, Licensed Psychologist 211 W Myrtle St, Ste 102 Fort Collins, CO 80521 970.491.9689 www.bethobrienphd.com Personal History Form Name: Date of Birth: Address: Home/cell phone: Work

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Dr. Beth O'Brien is a licensed professional, likely in the field of healthcare or mental health, holding the appropriate certifications and licenses to practice.

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The purpose of Dr. Beth O'Brien's licensing is to ensure that practitioners meet specific professional standards and regulations in order to provide safe and effective services.

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Information such as professional qualifications, work history, any disciplinary actions, current practice address, and continuing education credits must be reported.