• Sign up for a Psychological Evaluation

  • I am completing this form for:

  • Client's Demographic Information

    This demographic survey is meant to streamline your appointment. You do not need to spend a great deal of time on this. If your clinician has clarifying questions, they will ask you during your appointment. Brief statements are sufficient for most questions. All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.
  • Are you seeking services as part of a court order or relating to legal proceedings?*

  • We do not provide forensic services, nor do we accept referrals whose purpose is to generate evaluations or opinions for court. Our clinicians will not voluntarily write recommendation letters or appear in legal proceedings, and any compelled appearance will be billed and coordinated through clinic administration.

  • Do you require an interpreter?*

  • Contact Information

  • Format: 000-000-0000.
  • Relationship Status*
  • Employment status*

  • Emergency Contact Information

  • Format: 000-000-0000.

  • Health Information & History

  • Would you like your provider to speak with your primary care provider or any other care provider?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Indicate if you have been diagnosed with any of the following. Select all that apply.*
  • Do you have any current mental health diagnoses?*
  • Do you take any current medications for medical or mental health purposes?*
  • Are you currently receiving any of the following services?*
  • Rows

  • Familial/Relational Information

  • Do you have any children (if applicable)?
  • Please indicate which of the following ethnic/cultural/racial identities describe you. Select all that apply.*

  • Developmental Information

  • Which of the following has been experienced:
  • Select if any of the following apply to when your biological mother was pregnant with client:*
  • Rows
  • Have you received any of the following educational programs?*
  • Please indicate if any of the following describe your past or current educational experiences. Select all that apply.*
  • Level of Education*
  • Have you received psychological testing in the past?*
  • Have you ever wondered or been told that you have symptoms of any of the following? (please indicate even if you've already mentioned this information)*

  • Current & Past Symptoms

  • Select your current symptoms. Select all that apply.*
  • Have you ever been arrested?

  • Insurance Information

  • Do you have health insurance coverage?*
  • Do you have secondary health insurance coverage?*

  • I understand and agree to the following:

    • I authorize The Luminous Mind and its providers to release information from my health record to any insurance company or other third-party payer that is now, or later becomes, responsible for payment of my claims — whether listed above or provided to the practice later. This includes the information necessary to submit and process claims, such as my name, date of birth, address, mental health diagnosis, and the services provided to me.
    • This authorization and assignment apply to my current insurance and to any insurance coverage I have in the future. If my coverage changes, I am responsible for promptly giving the practice my updated insurance information; I do not need to sign a new authorization for the practice to bill the new payer.
    • This authorization allows the practice to verify my eligibility for benefits and to obtain payment for the services I receive. The practice will not refuse to treat me based on whether I sign this authorization, though a signed authorization is required for the practice to bill my insurance (see below).
    • I understand that information disclosed to a payer under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law (HIPAA).
    • This authorization remains in effect for the duration of my treatment with The Luminous Mind unless I revoke it. I may revoke it at any time by giving written notice to the practice. Revocation will not apply to information already shared before the practice receives my written notice. If I revoke this authorization while still in treatment, I understand I will be asked to make other financial arrangements to cover my charges.
    • In consideration of the services provided to me, I assign to The Luminous Mind all insurance benefits payable for those services, and I authorize any insurance company or third-party payer responsible for my claims — current or future — to make payment directly to The Luminous Mind on my behalf.
    • Insurance billing requires a completed and signed Insurance Authorization Form on file. If this form is not signed, my services will be billed as self-pay and I will be financially responsible for all charges incurred.
    • I am responsible for accurately disclosing all insurance coverage I have. If I fail to do so, I accept financial responsibility for any charges that result if other coverage is discovered later.
    • If I have not listed an insurance company, I attest that this is accurate and that I will not later ask the practice to bill insurance for these services ("back billing").
    • If I am using Medicare benefits, I also agree to the following: I request that payment of authorized Medicare benefits be made either to me or on my behalf to The Luminous Mind for any services furnished to me by the practice. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
       

  • Short-List for Last-Minute Cancellations

  • There is a long waiting list for testing; however, last-minute cancellations occasionally occur. Would you like to be added to the short-notice cancellation list and contacted if an appointment becomes available? Please note that the same time slot may be offered to multiple clients and will be scheduled with the first person who responds. If you are unable to accept an offered appointment, you will not lose your place on the waiting list.*
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