JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Psych Testing History Form
please be as through as possible
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Full name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Do you have access to our patient portal?
*
Yes
No
Other:
what insurance do you have and what is the phone number to behavioral health/provider services on the back of the card?
*
Your answer
Phone Number
Your answer
Race and Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other:
Clear selection
Presenting Problem
What are the symptoms that lead you to get testing?
Your answer
Are you currently under a Doctor’s Care? If so, for what reason? Who is your primary care?
Please list phone number
Your answer
When was your last physical?
MM
/
DD
/
YYYY
Have you seen Dr. Vora recently?
yes
no
Clear selection
Are you taking medication?
Please include medical and mental health medication dosage and the last time you took them
Your answer
Mental health medication history
Please list any medications you have tried in the past
Your answer
Do you regularly consume nicotine and/or caffeinated beverages? (coffee, an energy drink, or cigarettes)
*
nicotine
caffeinated beverages
Other:
Required
How often do you consume the above?
1-2 a day
more than 2 a day
less than 1 a day
Other:
Clear selection
Have you ingested any caffeinated beverages (e.g. coffee, tea, cocoa, or soft drinks) or have you smoked within 3-4 hours (recreational substance or nicotine).
yes
no
Clear selection
Are you currently taking antihistamines (allergy medications or for sleep) (i.e. hydroxyzine and Benadryl)? Indicate last use.
Your answer
Are you receiving lithium for a bipolar disorder?
Yes
No
Other:
Clear selection
Do you have extensive video game experience or are you highly trained athlete?
*
Yes
No
Maybe
Are/Have you been in Counseling previously? If so, with whom?
Your answer
Have you been hospitalized? (when and please explain reason)
Your answer
Family relationships and childhood history
(including your relationships with parents and siblings; bad, fair, good).
Your answer
Family History of mental health?
If yes who and describe symptoms
Your answer
Any developmental problems as a child?
did not meet milestones, or issues with pregnancy or after birth.
Your answer
How would you describe your social situation?
Few friends? lots of friends? supportive? was it easy making friends in school or work?
Your answer
Current Living Conditions
do you rent or own and who do you live with?
Your answer
Developmental History and Educational history (grade completed, your experience, special education)
Was school difficult for you? Did you often get i trouble? Any special education services?
Your answer
What types of work have you done and current work (i.e., labor, cashiering, gardening, teaching, construction,)
Please clarify past and current jobs
Your answer
How are your symptoms affecting your school/job performance?
Your answer
Has drinking alcohol or using any substances caused issues in your life? If yes please explain.
Please list any current or past history with substance abuse.
Your answer
How would you explain your history of substance use?
Please indicate what substances you have taken and when.
Your answer
Please list any mental or emotional symptoms that you may experience.
Has a health care diagnosed you with another mental health condition?
Your answer
Any health concerns or past surgeries?
Your answer
How is your sleep? (explain)
*
How many hours of sleep do you get? Do you feel rested?
Your answer
Do you consider yourself having risky behavior?
*
Sexual behaviors that are concerning
self harm or suicidal thoughts and behaviors
addictions (substance abuse, gambling)
binge eating
NO
Other:
What is your relationship status?
Please describe your sexual and gender identity as well as any issues with relationships.
Your answer
Do you have children?
If yes how many and what age? Biological?
Your answer
What would you say are your biggest life stressors?
Your answer
Is there anything else that you may want the office to know?
Your answer
1. If you miss your appointment or do not cancel within 24 hours you agree to be charged a 100$ cancellation fee.
2. You are aware that insurance may not cover psychological testing and self pay is determined by the type of testing required. (i.e. if results indicate the T.O.V.A is required the first session is an additional 100$. If medication is being used and Dr. Vora requires additional sessions to monitor treatment an additional 50$ will be required for each follow up session.)
3. N
o caffeinated beverages (e.g. coffee, tea, cocoa, or soft drinks) should be ingested on the day of a test. Nor should you have smoked within 3-4 hours (recreational substance or
nicotine
).
4. You are aware the t
esting is done by a technician and is supervised by a Board Certified Child and Adult Psychiatrist and that some insurances require a Licensed Psychologist to perform full psychological testing.
agree
do not agree
Clear selection
Signature
Please type your full legal name below indicating you agree with the above information.
Your answer
Date
MM
/
DD
/
YYYY
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
