• New Client Interest Form

  • Welcome to Change Point Psychology! Please complete this confidential form so we can make sure that we are the best fit for your needs.

  • I am completing this form for _______ .*
  • Change Point Psychology LLC should follow up with _______ .*
  • Format: (000) 000-0000.
  • Are you or the prospective client over 18 years of age?*
  •  - -
  • Format: (000) 000-0000.
  • Please select your insurance provider:*
  • I am out of network, and would like to receive documentation (i.e. Superbills) to file my own insurance claims.*
  • What is your preferred therapy format? Please select all that apply to you.*
  • What is your preferred format for communication? Please select all that apply.*
  • Have you been hospitalized for a psychological issue or problem within the last six months (e.g., inpatient hospitalization, IOP, PHP)?*
  • Have you ever experienced or witnessed anything traumatic that continues to cause you distress and/or interfere with day-to-day life?*
  • I have been diagnosed with bipolar disorder, or think I may have experienced a manic episode.*
  • In the past year, I have regularly (e.g., daily/weekly) used illegal drugs or prescription medications in ways that were not prescribed.*
  • My alcohol/drug use causes problems, interferes with my life, and/or causes concern for my family/friends.*
  • My upbringing/family circumstances has affected me ________.*

  • At this time Change Point Psychology LLC is only serving adult clients (18+). Please feel free to reach out to us by phone with any questions or concerns regarding this policy.

     

    (614) 285-7427‬

  • ASRS-5

  • Question 1: How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?*
  • Question 2: How often do you leave your seat in meetings or other situations in which you are expected to remain seated?*
  • Question 3: How often do you have difficulty unwinding and relaxing when you have time to yourself?*
  • Question 4: When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?*
  • Question 5: How often do you put things off until the last minute?*
  • Question 6: How often do you depend on others to keep your life in order and attend to details?*

  • Symptoms 1

  • I experience excessive anxiety and worry.*
  • This anxiety or worry has occurred more days than not over the last 6 months.*
  • Please select all that apply. I have noticed the following symptoms:*
  • How difficult have these symptoms made your life?*

  • Symptoms 2

  • Please select all that apply. I have noticed the following symptoms:*
  • Please select all that apply. These symptoms impact my ability to lead a fulfilling life at:*

  • Mood-related concerns

  • Select all the symptoms that are concerning to you and often interfere with your day-to-day life:*
  •  - -

  • SLEEP

  • Select all the symptoms that are concerning to you and often interfere with your day-to-day life:*
  •  - -

  • APPETITE/WEIGHT

  • Select all the symptoms that are concerning to you and often interfere with your day-to-day life:*
  •  - -

  • Mania

  • Select all the symptoms that are concerning to you and often interfere with your day-to-day life:*
  •  - -

  • Concentration

  • Select all the symptoms that are concerning to you and often interfere with your day-to-day life:*
  •  - -
  • Should be Empty: