The Luminous Mind
TESTING REGISTRATION FORM
ALERT: Please be aware that wait times for psychological testing are now an average of 18 months.
I am completing this form for:
Myself (I am over 18)
Myself (I am under 18 but am a legally emancipated minor)
Someone Else (parent or legal guardian of a minor)
Someone Else (court appointed legal guardian of an adult)
Name of person completing this form
*
FIRST NAME
LAST NAME
Date of birth of person completing this form
*
-
Month
-
Day
Year
Relationship to client
*
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.
Client's Full Name
*
FIRST NAME
LAST NAME
Client's Preferred Name (if different from legal name)
Client's Age
*
Client's Date of Birth
*
/
Month
/
Day
Year
Legal Sex
*
Please Select
Male
Female
REQUIRED FOR BILLING PURPOSES
Client's Social Security Number
*
ENTER 0's IF YOU DO NOT HAVE A SS NUMBER
Gender Identity
Please Select
Male
Female
Non-binary
Genderqueer
Agender
Two-spirit
Transgender
OPTIONAL
Pronouns
Please Select
he/him/his
she/her/hers
they/them/theirs
others
OPTIONAL
Sexual Orientation
OPTIONAL
Please indicate which of the following ethnic/cultural/racial identify you. Select all that apply.
*
African American
Black
Caucasian
Central African
East Asian
East African
European
Hispanic
Jewish
Latine/Latinx
Middle Eastern/North African
Mixed Race
Native American
North African
Pacific Islander
South Asian
West African
White
Unknown
Other
Do require an interpreter?
*
Yes
No
What language(s) do you speak?
*
Please indicate if there are accessibility needs or accommodations that we should be aware of:
Contact Information
Address
*
STREET ADDRESS
APARTMENT OR UNIT NUMBER
CITY
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
STATE
ZIP CODE
Phone Number
*
Email
*
May we leave detailed voicemails if needed?
*
Yes
No
(Optional) Our system's default is send email and sms reminders for appointments. Please inform us of any objections or special requests regarding this matter.
Emergency Contact Information
Indicate the name of someone you would like us to notify in case of an emergency:
*
FIRST NAME
LAST NAME
Relationship to emergency contact
*
Phone number of emergency contact:
*
Would you like your provider to speak with your primary care provider? If yes, we will ask you for the provider's name and contact information
*
Yes
No
Name of provider you want to sign a release of information for:
*
First Name
Last Name
Fax Number
*
Please enter a valid phone number.
Phone Number
*
Please enter a valid phone number.
Name and contact information for provider that you would like to sign a release of information for. Please include Name and fax number in addition to other contact information
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Overview information
Client strengths
What are you hoping to find out through a psychological evaluation?
*
Do you have any current mental health diagnoses?
*
Yes
No
Current diagnoses
Do you take any current medications for medical or mental health purposes?
*
Yes
No
Current medications
Do you have any current mental health services (therapy, medication management, case management, etc.)?
*
Yes
No
Current services
Familial/Relational Information
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.
Relationship Status
*
Single
Married
Partnered
Engaged to be married
Divorced
Separated
Widowed
Not Applicable (child)
Do you have any children?
Yes
No
Please add the names and ages of your children
*
Living Situation
*
Family/Social Relationships
*
Family Background
*
Cultural/Ethnic Background
*
Religiosity & Spirituality
*
Developmental Information
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.
Which of the following has been experienced:
Parental Divorce/Separation (before 18)
Frequent Moving (before 18)
Neglect (before 18)
Health Issues (before 18)
Abandonment (before 18)
Sexual Abuse (before 18)
Parental/Caregiver illness or death (before 18)
Emotional Abuse (before 18)
Feeling Unloved (before 18)
Physical Abuse (before 18)
Fertility Issues
Loss of Child
Familial Rejection
Familial/Caregiver substance abuse (before 18)
Custody Conflicts (before 18)
Adoption (domestic)
Sibling Death (before 18)
Adoption (International)
Group Home placement
Bullying
Dangerous Car Accident
Foster Care placement
Natural Disaster(s)
War and Displacement
Homelessness
Immigration
House Fire
Sexual Assault
Community Violence
Domestic abuse
Military Deployment
None
Additional Information
*
Select if any of the following apply to when your biological mother was pregnant with client:
*
Pregnancy complication
Prenatal exposure to alcohol, tobacco, or drugs
Birth prior to 37 weeks (pre-term)
Post-term depression
Medications during pregnancy
Delivery complications
Low or high birth weight
Forceps or vacuum assisted delivery
Complications after delivery
None
Other
Additional Information
Select what applies to how you met your developmental milestones (crawling, walking, talking, toilet training, etc) from birth to 5 years old.
Information unknown
All milestones were within normal (expected) time
Some milestones were early or late
Developmental milestones of client:
*
Early
Average/within normal limits
Delayed
Unsure
Gross motor skills (walking, running)
Fine motor skills (buttons, shoe laces, zippers, handwriting)
Expressive language (talking)
Receptive language (understanding language)
Self-care skills (dressing, feeding, toilet training)
Emotion regulation
Social skills
Cognitive development
Additional Information
Have you received any of the following educational programs?
*
Special Education (ex. IEP, 504 Accommodation Plan)
Tutoring
Enrichment Programs
Counseling
Accommodations
After-School Programming
Mentoring
None
Other
Please indicate if any of the followed describe your past or current educational experiences. Select all that apply.
Low Grades/Performance
Procrastination
Difficulty Understanding
Friendship Difficulties
Poor Attendance
Tardiness
Skipping School
School Avoidance
Detention
Suspension from school
Expulsion from school
Being held back a year
Bullying Others
Being Bullied
Educational Experiences:
*
Have you received psychological testing in the past?
*
Yes
No
Additional Information
Level of Education
*
Less than High School
High School or GED
Technical School
Bachelor Degree
Graduate or Professional Degree
Employment status
*
Working full time
Working part time
Unemployed
Employed Student
Unemployed Student
Disabled
Retired
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Health Information & History
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.
Name of Primary Health Care Provider and Clinic
*
When was your last physical exam?
*
Indicate if you have been diagnosed with any of the following. Select all that apply.
*
Anemia
Anorexia
Autism
Attention Deficit Hyperactivity Disorder (ADHD)
Avoidant Restrictive Food Intake Disorder (ARFID)
Bipolar Disorder
Cancer
Chronic Fatigue Syndrome
Cognitive/Intellectual Delays
Dissociative Identity Disorder (DID)
Fibromyalgia
Generalized Anxiety Disorder
HIV
Irritable Bowl Syndrome
Learning Disability
Major Depressive Disorder
Mast Cell Activation Syndrome (MCAS)
Migraines
Oppositional Defiant Disorder
Panic Disorder
Pediatric Autoimmune Neuropsychiatric Disorder (PANDAS)
Poly Cystic Ovarian Syndrome (PCOS)
Post Traumatic Stress Disorder (PTSD)
Sensory Processing Disorder
Thyroid Problems
Traumatic Brain Injury (TBI)
Vitamin Deficiency
None of the above
Other
Additional Information
Are you currently receiving any of the following services?
*
Psychotherapy
Outpatient Psychiatry
Case Management
Day Treatment
Inpatient Psychiatric Care
Residential Treatment
Crisis Care
None
Other
Additional Information
List current medications or supplements and how often you take them:
Indicate your use of the following substances
*
Indicate Use
Tobacco (cigarettes, hookah, vaping, chewing)
Never Used
Former Use
Rarely
Occasionally
Frequently
Alcohol
Never Used
Former Use
Rarely
Occasionally
Frequently
Marijuana
Never Used
Former Use
Rarely
Occasionally
Frequently
Hallucinogens (LSD, Khat, MDMA, psilocybin)
Never Used
Former Use
Rarely
Occasionally
Frequently
Opioids (pain killers, heroin, morphine, kratom)
Never Used
Former Use
Rarely
Occasionally
Frequently
Stimulants (cocaine, methamphetamine)
Never Used
Former Use
Rarely
Occasionally
Frequently
Additional Information
Current & Past Symptoms
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.
Select your current symptoms. Select all that apply.
*
Anger Outbursts
Difficulty Concentrating
Academic Difficulties
Sadness
Flashbacks
Sexual Dysfunction
Forgetfulness
Excessive Worry
Lack of Pleasure or Interest
Self-Harm
Panic Attacks
Suicidal Thoughts
Irritability
Confusion
Weight Loss
Weight Gain
Impulsivity
Hyperactivity
Fatigue
Loneliness
Hallucinations
Obsessive Thoughts
Gender Dysphoria
Relationship Difficulties
Physical Pain
Occupational Difficulties
Anxiety
Sensory Overload
Eating Difficulties
Sleep Difficulties
Excessive Fear
None of the above
Other
Additional Information
Client Strengths & Sources of Resilience
*
Do you have any past or current safety/risk issues (self-harm, suicidal ideation, etc)?
Yes
No
Additional Information
Are you seeking services as part of a court order or relating to legal proceedings?
*
Yes
No
Please be aware that we do NOT conduct any forensic, custody, or court ordered services.
Have you ever been arrested?
Yes
No
Additional Information
How did you hear about The Luminous Mind? (Who referred you)
*
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Insurance Information
Select your PRIMARY health insurance carrier
*
Please Select
I do not have insurance and want to Self-Pay
Aetna
Blue Cross Blue Shield (PMAP/MA)
Blue Cross Blue Shield (Commercial)
Health Partners (PMAP/MA)
Health Partners (Commercial)
Medicaid (MA/Medical Assistance)
Medicare Plan B
Ucare (PMAP/MA)
Ucare (Commercial)
Other (Not covered) but want to Self-Pay
Member ID
*
Group Number
*
Select your SECONDARY health insurance carrier
*
Please Select
I do not have secondary insurance
Aetna
Blue Cross Blue Shield (PMAP/MA)
Blue Cross Blue Shield (Commercial)
Health Partners (PMAP/MA)
Health Partners (Commercial)
Medicaid (MA/Medical Assistance)
Medicare Plan B
Ucare (PMAP/MA)
Ucare (Commercial)
Other (Not covered)
Member ID
*
Group Number
*
Short-List for Last-Minute Cancellations
There is a long waiting list for testing, though at times there are last minute cancellations. Would you like to be added to the list of clients that are contacted on short-notice if something opens up? If you indicate that you would like to be added to this list, please be advised that you and others may be offered the same time and it will be offered to whomever responds first. If you are unable to take an offered time slot, you will not lose your place on the waiting list.
*
Yes
No
I attest that the information that I have provided in this form is correct to the best of my knowledge. I attest that my name and identity are correct and that I am legally authorized to complete this form.
*
Name
*
First Name
Last Name
DateTime
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