Psychological Assessment Form

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CONSENT
This form is used to provide you with information about our institution and to gain your approval for services to be provided. Please read this form thoroughly and bring any questions or concerns to the attention of the intake interviewer.
You will receive mental health services in the form of psychological assessment(s) and therapy. The goal of the evaluation is to evaluate the nature of, and the extent to which, you may be experiencing psychological or emotional difficulties as a result of your injury, as well as to provide treatment recommendations. The scope of the evaluation is mostly limited to symptoms found frequently in MVA situations (e.g., anxiety, depression, trauma, phobia).
Telepsychology services
Video conferencing provides benefits and drawbacks that are distinct from face-to-face meetings (e.g., patient confidentiality).
Telepsychology services are still private, and no one will record a session without the consent of the other party(s).
We agree to use the video-conferencing platform that the psychotherapist/psychologist has selected for our virtual sessions, and we will be shown how to use it by the psychotherapist/psychologist.
You must utilize a webcam or a smartphone during the session.
You should be in a quiet, secluded location free of distractions during the session (such as telephones or other electronics).
It is vital to have a secure internet connection rather than using public or free Wi-Fi.
Acknowledgment & Consent
I have read and fully comprehended the preceding information and agree to seek clarification if I have any questions about the treatment process, its goals, procedures, potential dangers, or expected outcomes. I accept that I am allowed to terminate services at any moment for any reason. I am aware that the security of my information has some limitations.
By signing below, I accept that this institution may collect, use, and disclose personal information about me in the ways described above.
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Client's Name* This field is required.
First Name
Last Name
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Date* This field is required.
Date
Month
Day
Year
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Signature* This field is required.
Clear
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By signing this form, I acknowledge that I am the only person providing answers to the questionnaire, and that I am doing so without supervision or assistance.
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I'm constantly concerned about whether or not the pain will subside.* This field is required.
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Not at all
Always
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I'm afraid I won't be able to go on.* This field is required.
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Not at all
Always
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It's bad, and I don't think it'll ever get better.* This field is required.
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Not at all
Always
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It's terrible, and I'm feeling overwhelmed.* This field is required.
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Not at all
Always
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I'm at the point where I can't take it any longer.* This field is required.
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Not at all
Always
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I'm concerned that the pain will worsen.* This field is required.
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Not at all
Always
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I can't stop thinking about previous traumatic incidents.* This field is required.
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Not at all
Always
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I'm desperate for the agony to go away.* This field is required.
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Not at all
Always
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I just can't get it out of my head.* This field is required.
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Not at all
Always
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I'm constantly reminded of how much it aches.* This field is required.
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Not at all
Always
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There's nothing I can do to make the anguish less intense.* This field is required.
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Not at all
Always
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I'm concerned that something severe may occur.* This field is required.
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Not at all
Always
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I'm always thinking about how much I want the suffering to end.* This field is required.
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Not at all
Always
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The majority of people are unaware of the severity of my disease.* This field is required.
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Rarely
Always
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I'll never be the same again.* This field is required.
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Rarely
Always
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I am suffering as a result of someone else's carelessness.* This field is required.
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Rarely
Always
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No one should be forced to live in this manner.* This field is required.
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Rarely
Always
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All I want is to reclaim my life.* This field is required.
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Rarely
Always
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I believe this has had a long-term impact on me.* This field is required.
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Rarely
Always
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It all appears to be so unjust.* This field is required.
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Rarely
Always
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I'm concerned that my illness isn't being addressed seriously.* This field is required.
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Rarely
Always
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Nothing can ever be enough to compensate for everything I've been through.* This field is required.
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Rarely
Always
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I feel as if I've been robbed of something extremely valuable.* This field is required.
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Rarely
Always
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I'm worried that I won't be able to fulfill my goals.* This field is required.
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5
Rarely
Always
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I'm shocked that this has happened to me.* This field is required.
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4
5
Rarely
Always
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Despair * This field is required.
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3
4
5
Not at all
All the time
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Pleasure Loss * This field is required.
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5
Not at all
All the time
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Failures in the past* This field is required.
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Not at all
All the time
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Feelings of Shame* This field is required.
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5
Not at all
All the time
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Feelings of Punishment* This field is required.
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5
Not at all
All the time
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Dislike of yourself* This field is required.
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5
Not at all
All the time
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Self-criticism* This field is required.
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5
Not at all
All the time
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Suicidal Wishes or Thoughts* This field is required.
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Not at all
All the time
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Crying* This field is required.
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Not at all
All the time
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Loss of enthusiasm* This field is required.
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5
Not at all
All the time
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Worthlessness* This field is required.
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5
Not at all
All the time
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Energy Depletion* This field is required.
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4
5
Not at all
All the time
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Sleeping Pattern Alterations* This field is required.
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4
5
Not at all
All the time
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Appetite Alterations* This field is required.
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5
Not at all
All the time
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Difficulty in Concentration* This field is required.
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5
Not at all
All the time
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Fatigue or tiredness* This field is required.
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Not at all
All the time
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Loss of lust for sex* This field is required.
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Not at all
All the time
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Tingling or numbness* This field is required.
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Not at all
All the time
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I'm sweltering* This field is required.
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Not at all
All the time
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Leg tremors* This field is required.
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Not at all
All the time
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Inability to calm down* This field is required.
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Not at all
All the time
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Fear of the worst-case scenario* This field is required.
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5
Not at all
All the time
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Feeling dizzy or lightheaded* This field is required.
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Not at all
All the time
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Your heart is thumping or racing* This field is required.
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Not at all
All the time
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Unstable* This field is required.
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5
Not at all
All the time
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Choking sensations* This field is required.
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5
Not at all
All the time
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Trembling hands* This field is required.
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5
Not at all
All the time
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Fear of letting control go* This field is required.
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5
Not at all
All the time
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Breathing problems* This field is required.
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5
Not at all
All the time
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Fear of death* This field is required.
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5
Not at all
All the time
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Abdominal ache or indigestion* This field is required.
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Not at all
All the time
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Faint* This field is required.
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Not at all
All the time
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A flushed face* This field is required.
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Not at all
All the time
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Sweating is a common occurrence (not because of the heat)* This field is required.
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Not at all
All the time
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Did you have a lot of driving experience prior to the accident?* This field is required.
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Not at all
All the time
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Do you have a lot of anxiety as a driver these days?* This field is required.
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Not at all
All the time
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Do you think your driving anxiety is interfering with your life in any way? For example, because you avoid traveling on highways, you see your friends and family less frequently or need more time to get to work.* This field is required.
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Not at all
All the time
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While driving, I experienced instant terror, fear, or fright.* This field is required.
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5
Not at all
All the time
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Worried, uneasy, or nervous about driving.* This field is required.
1
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5
Not at all
All the time
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While driving, you experienced a racing heart, sweating, difficulty breathing, fainting, or shakiness.* This field is required.
1
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5
Not at all
All the time
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Had problems relaxing in while driving due to stiff muscles, feeling on edge or restless* This field is required.
1
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5
Not at all
All the time
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Driving was avoided or avoided entirely* This field is required.
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Not at all
All the time
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I stopped or moved away from driving sooner than I should have* This field is required.
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Not at all
All the time
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I've spent a lot of time either preparing for or putting off driving* This field is required.
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5
Not at all
All the time
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I diverted my attention away from driving* This field is required.
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5
Not at all
All the time
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To cope with driving, I required assistance (e.g., alcohol or medications, superstitious objects, other people)* This field is required.
1
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5
Not at all
All the time
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Please choose the best to define yourself.
Disagree
Neutral
Agree
I usually get a good night's sleep. 
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
I always have the best intentions for the majority of people.
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
I am able to do my work and household tasks.
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
I don't have any more pain issues than the average person.
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Most mornings, I wake up feeling fairly good.
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Rather than telling folks the unpleasant truth, I may occasionally tell them what I think they want to hear.
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
I frequently feel unhelpful to myself and others.
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
My memory isn't as sharp as it once was.
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
The vast majority of people appear to be in better overall health than I am.
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
I don't appear to be as content as the majority of individuals.
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
I have to work hard at times to maintain my focus.
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
I appear to be more prone to fatigue than the majority of people.
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
It appears that some individuals treat me unfairly.
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
I am uninterested in extracurricular activities and other people.
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
I usually live in harmony with myself and others.
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
I suffer from more headaches than the average person. 
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
I believe that the majority of people are only concerned with themselves and are unconcerned about others.
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
When I'm in a bunch of people, I become a little nervous.
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
I'm more easily irritated than I used to be.
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
I'm more easily irritated than I used to be.
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
I occasionally believe that everyone would be better off if I died.
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
I have a number of significant regrets in my life.
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
My life is very wonderful, save from a few little issues.
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
I feel pain in my hand or foot on occasion.
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
My heart seems to beat excessively hard and fast a lot of the time.
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
I am both pleased and sad at times.
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
I usually get a good night's sleep. 
I always have the best intentions for the majority of people.
I am able to do my work and household tasks.
I don't have any more pain issues than the average person.
Most mornings, I wake up feeling fairly good.
Rather than telling folks the unpleasant truth, I may occasionally tell them what I think they want to hear.
I frequently feel unhelpful to myself and others.
My memory isn't as sharp as it once was.
The vast majority of people appear to be in better overall health than I am.
I don't appear to be as content as the majority of individuals.
I have to work hard at times to maintain my focus.
I appear to be more prone to fatigue than the majority of people.
It appears that some individuals treat me unfairly.
I am uninterested in extracurricular activities and other people.
I usually live in harmony with myself and others.
I suffer from more headaches than the average person. 
I believe that the majority of people are only concerned with themselves and are unconcerned about others.
When I'm in a bunch of people, I become a little nervous.
I'm more easily irritated than I used to be.
I'm more easily irritated than I used to be.
I occasionally believe that everyone would be better off if I died.
I have a number of significant regrets in my life.
My life is very wonderful, save from a few little issues.
I feel pain in my hand or foot on occasion.
My heart seems to beat excessively hard and fast a lot of the time.
I am both pleased and sad at times.
Disagree
Row 0, Column 0
Neutral
Row 0, Column 1
Agree
Row 0, Column 2
Disagree
Row 1, Column 0
Neutral
Row 1, Column 1
Agree
Row 1, Column 2
Disagree
Row 2, Column 0
Neutral
Row 2, Column 1
Agree
Row 2, Column 2
Disagree
Row 3, Column 0
Neutral
Row 3, Column 1
Agree
Row 3, Column 2
Disagree
Row 4, Column 0
Neutral
Row 4, Column 1
Agree
Row 4, Column 2
Disagree
Row 5, Column 0
Neutral
Row 5, Column 1
Agree
Row 5, Column 2
Disagree
Row 6, Column 0
Neutral
Row 6, Column 1
Agree
Row 6, Column 2
Disagree
Row 7, Column 0
Neutral
Row 7, Column 1
Agree
Row 7, Column 2
Disagree
Row 8, Column 0
Neutral
Row 8, Column 1
Agree
Row 8, Column 2
Disagree
Row 9, Column 0
Neutral
Row 9, Column 1
Agree
Row 9, Column 2
Disagree
Row 10, Column 0
Neutral
Row 10, Column 1
Agree
Row 10, Column 2
Disagree
Row 11, Column 0
Neutral
Row 11, Column 1
Agree
Row 11, Column 2
Disagree
Row 12, Column 0
Neutral
Row 12, Column 1
Agree
Row 12, Column 2
Disagree
Row 13, Column 0
Neutral
Row 13, Column 1
Agree
Row 13, Column 2
Disagree
Row 14, Column 0
Neutral
Row 14, Column 1
Agree
Row 14, Column 2
Disagree
Row 15, Column 0
Neutral
Row 15, Column 1
Agree
Row 15, Column 2
Disagree
Row 16, Column 0
Neutral
Row 16, Column 1
Agree
Row 16, Column 2
Disagree
Row 17, Column 0
Neutral
Row 17, Column 1
Agree
Row 17, Column 2
Disagree
Row 18, Column 0
Neutral
Row 18, Column 1
Agree
Row 18, Column 2
Disagree
Row 19, Column 0
Neutral
Row 19, Column 1
Agree
Row 19, Column 2
Disagree
Row 20, Column 0
Neutral
Row 20, Column 1
Agree
Row 20, Column 2
Disagree
Row 21, Column 0
Neutral
Row 21, Column 1
Agree
Row 21, Column 2
Disagree
Row 22, Column 0
Neutral
Row 22, Column 1
Agree
Row 22, Column 2
Disagree
Row 23, Column 0
Neutral
Row 23, Column 1
Agree
Row 23, Column 2
Disagree
Row 24, Column 0
Neutral
Row 24, Column 1
Agree
Row 24, Column 2
Disagree
Row 25, Column 0
Neutral
Row 25, Column 1
Agree
Row 25, Column 2
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