New Client Interest Form

myself, I am the prospective client.someone else who is interested in therapy.

me, the person completing this form nowthe potential client

Please enter a valid phone number.

Jonathan Shay, Ph.D. (Diagnostic evaluation: $350; 55 min: $265; 45 min: $200)

Telehealth/Video ConferenceIn-person

I acknowledge that insurance may not cover session costs outside of the state of Ohio, and I will be responsible for covering the cost of the session.

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

Restlessness or feeling keyed up or on edgeBeing easily fatiguedDifficulty concentrating or mind going blankIrritabilityMuscle tensionSleep disturbance (e.g., difficulty falling or staying asleep, restless or unsatisfying sleep)

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Depressed mood.Loss of interest or pleasure in things/activities I used to enjoy.Significant weight loss/gain within one month's time.Significant increase/reduction of appetite within one month's time.Noticeable change (increase/decrease) in sleep length or quality.Noticeable agitation or slowing in daily speech and/or behaviors severe enough to be observed by others.Tiredness, fatigue, or low energy, or decreased efficiency in completing daily tasks.A sense of worthlessness or excessive or obviously inappropriate guilt.Impaired ability to think, concentrate, or make decisions that you experience or others observe.

work.in my social circles.in several areas of life important to me (outside of my work and social lives).These symptoms do not affect my functioning in any noteworthy way.

Long-lasting euphoric, unusually-happy, or irritable moodsDecreased need for sleep (e.g., feeling rested after only a few hours of sleep)Notably increased energy and goal-directed activity (i.e. a desire to thoroughly clean the whole house that seems come "out of nowhere").Grandiosity or unusually high sense of self-esteem or confidenceRacing thoughts and speech that is difficult to stopDistractibilityAgitation or restlessness that is difficult to ignore

Great difficulty starting tasksGreat difficulty completing tasksGreat difficulty sticking-with tasksDifficulties concentrating on academic workDifficulties concentrating on readingDifficulties concentrating on conversationsDifficulty focusing on one thought/task at a timeProcrastinating

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.

ASRS-5

Symptoms 1

Symptoms 2

Mood-related concerns

SLEEP

APPETITE/WEIGHT

Mania

Concentration