Labor and Industries Intake with Whodas, PHQ, and PCL

Columbia Basin Psychological Services LLC

Licensed Psychologist

7015 W Deschutes Ave Suite B

Kennewick, WA 99336

Phone: 509-572-2126 Fax: 855-841-4215 Email: office@cbpsych.net
Injured Worker Therapy Consent to Treat and Intake Form
Full Name*
Todays Date*

MonthDayYear
Date
Mailing Address*
Gender*
Birth Date*

MonthDayYear
Date
State*
City*
Zip*
Emergency Contact Name*
Emergency Contact Phone number*
Relationship*
CLAIM INFORMATION
Claim Number*
Insured by (L&I, Penser, other)*
Claim Manager's Name*
Claim Manager's Phone Number*
Referring Provider Name and Number*
Date of Injury*

MonthDayYear
Date
Describe injury:*
Treatment to this point*
In your Opinion what have been the psychological effects of the injury treatments*
*My signature on this form indicates my agreement to participate in treatment related to my claim and authorizes contact between Dr. Marks, my treating physician, and the insurance company staff.

*I agree to participate in treatment to the best of my abilities, including completing weekly homework assignments and reading.

*My signature on this form authorizes the release of medical information necessary to process this claim for payment through my insurance carrier and/or to my treating provider.

*I am responsible for a $50 No-Show fee if I fail to show up for my appointment or if I call and cancel less than 24 hours before my appointment.
Signature*

Clear
Date*

MonthDayYear
Date
Columbia Basin Psychological Services LLC

Licensed Psychologist 7015 W Deschutes Ave

Phone: :509-572-2126 Fax: 855-841-4215 Email: office@cbpsych.net
AUTHORIZATION FOR EXCHANGE OF INFORMATION
Name*
Today's Date*

MonthDayYear
Date
Gender
Birth Date*

MonthDayYear
Date
Mailing Address*
City*
State*
Zip*
Emergency Contact Name*
Emergency Contact Phone number*

Area CodePhone Number
Emergency Contact Relationship
My signature on this form authorizes contact and information sharing between Dr. N.K. Marks and the parties below:
Name*
Address*
Phone number*
Reason for Release (check all that apply)*

Continuity of CareLabor and Industries ClaimAttorneyNext of Kin/AdvocateSocial Services ProviderEducationalDrug and Alcohol TxOther
Signature*

Clear
Limits of Exchange
Date

MonthDayYear
Date
Dates of Reauthorization
Date

MonthDayYear
Date
Initial
Date

MonthDayYear
Date
Initial
WHODAS 2.0
Claim number*
Name*
Today's Date*

MonthDayYear
Date
World Health Organization Disability Assessment Schedule 2.0

This questionnaire asks about difficulties due to health/mental health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long-lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please select only one response.

In the past 30 days, how much difficulty did you have in:*

	None(1)	Mild(2)	Moderate (3)	Severe(4)	Extreme or Cannot Do(5)
Standing for long periods such as 30 minutes?
Taking care of your household responsibilities?
Learning a new task, for example, learning how to get to a new place?
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health problems?
Concentrating on doing something for ten minutes?
Walking a long distance such as a kilometer [or equivalent]? 1 kil = .62 miles
Washing your whole body?
Getting dressed?
Dealing with people you do not know?
Maintaining a friendship?
Your day-to-day work?

Overall, in the past 30 days were these difficulties present?*
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition*
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut or reduce your usual activities or work because of any health condition?*
GAD-7

Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious or on edge*
2. Not being able to stop or control worrying*
3. Worrying too much about different things*
4. Trouble Relaxing*
5. Being so restless that it is hard to sit still*
6. Becoming easily annoyed or irritable*
7. Feeling afraid as if something awful might happen*
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
Full Name*
DATE*

MonthDayYear
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things*
2. Feeling down, depressed, or hopeless*
3. Trouble falling or staying asleep, or sleeping too much*
4. Feeling tired or having little energy*
5. Poor appetite or overeating*
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down*
7. Trouble concentrating on things, such as reading the newspaper or watching television*
8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual*
9. Thoughts that you would be better off dead or of hurting yourself in some way*
If you checked off any problems. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*
PCL-5

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the numbers to indicate how much you have been bothered by that problem in the past month.
Name*

First NameLast Name
In the past month, how much were you bothered by:
1. Repeated, disturbing, and unwanted memories of the stressful experience?*
2. Repeated, disturbing dreams of the stressful experience?*
3. Suddenly feeling or acting as If the stressful experience were actually happening again (as If you were actually back there reliving it)?*
4. Feeling very upset when something reminded you of the stressful experience?*
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?*
8. Trouble remembering important parts of the stressful experience?*
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there Is something seriously wrong with me, no one can be trusted, the world Is completely dangerous)?*
10. Blaming yourself or someone else for the stressful experience or what happened after it?*
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
12. Loss of Interest In activities that you used to enjoy?*
13. Feeling distant or cut off from other people?*
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
15. Irritable behavior, angry outbursts, or acting aggressively?*
16. Taking too many risks or doing things that could cause you harm?*
17. Being "superalert'' or watchful or on guard?*
18. Feeling Jumpy or easily startled?*
19. Having difficulty concentrating?*
20. Trouble falling or staying asleep?*
Should be Empty:

Injured Worker Therapy Consent to Treat and Intake Form

CLAIM INFORMATION

AUTHORIZATION FOR EXCHANGE OF INFORMATION

My signature on this form authorizes contact and information sharing between Dr. N.K. Marks and the parties below:

Dates of Reauthorization

WHODAS 2.0

GAD-7

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

PCL-5

In the past month, how much were you bothered by: