Evaluation

Question 14. Do you try to avoid people or places that remind you of the traumatic event? *

Yes

If you answered YES above please explain how your worrying interferes with your daily life activities. Please provide as much information as possible.

Part VII. (MD) Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. -------------- QUESTION 60. Do you often feel sad or depressed for unknown reasons? *

Yes

QUESTION 63. Has your depression or feelings of sadness caused significant changes in appetite, causing you to eat significantly more or less? *

Yes

If you answered YES above please explain below in what way the depression interferes with your daily life. Please provide as many details as possible.

Part IV GAD Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. ----------------- QUESTION 27. During the past six months have you been frequently worried about big or small events in your life? *

Yes

Part V. (PD) - Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. ---------------- QUESTION 39. Have you ever experienced sudden and unexpected intense fear or anxiety for no apparent reason (panic attack) or in situations where you did not expect it to occur in the past 6 months? *

Yes

QUESTION 64. If you answered YES above, in the last 3 months how long has your appetite been increased or decreased ? Very Mild (one week or less); Mild (one week to two weeks), Moderate to Severe (two weeks to one month) Severe (more than one month) or None of the above. *

None

One week or less

One to two weeks

Two weeks to one month

More than one month

Keystone Psychological Services - Psychological Evaluation

The following exam consists of seven parts with 73 total questions that should take approximately 30-45 minutes to complete. Each question MUST be answered (unless indicated as optional).

There is no time limit so PLEASE TAKE YOUR TIME and provide complete answers to all questions. Evaluations lacking sufficient information will be rejected.

If a question does not apply to you please answer "No" or "None" in the appropriate field. If a required question is left blank you will not be able to submit the exam.

When finished please click the "checkout" tab which will save your exam on our server and lead you to a Payment review page. Once payment is completed please allow 2-3 business days for your test results and prescription if a diagnosis can be made.

Please note the airline rules have changed and air carriers will not accept ESA's for reservations made after March 1st 2021. Housing prescriptions will continue to be protected under the Fair Housing Act.

QUESTION 51. Do your panic attacks or fear of future panic attacks interfere with any of your major life activities? Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. *

Yes

Question 18. Since the traumatic event have you felt irritable or had outbursts that you had difficulty controlling? *

Yes

QUESTION 59. Does the feared activity in question #53 interfere with any of your major life activities? Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. *

Yes

Question 2. External Emotional Symptoms: In the past year have you experienced any significant external emotional symptoms such as crying, trembling, shortness of breath, head aches, or any other negative symptom of your emotions. *

QUESTION 35. When worried do you have frequently have difficulty sleeping? *

Yes

QUESTION 30. Do you think you worry about things too much? *

Yes

QUESTION 69. If you answered YES above, in the last 3 months how often have you experienced feelings of worthlessness or low self-esteem? Short term (one week or less); Mild (one week to two weeks), Moderate (two weeks to one month) Severe (more than one month) or None of the above.

One week or less

One to two weeks

Two weeks to one month

More than one month

None of the above

QUESTION 38. Does your worrying interfere with any major life activity? (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.) *

Yes

Gender *

Male

Female

Non Binary

Question 19. Since the traumatic event took place do you have difficulty sleeping? *

Yes

By signing below (you can use your computer mouse) I hereby give my consent for electronic therapy for my care and have read and comprehend the definition of electronic therapy herein. I agree to share my health information with my assigned therapist in compliance with federal privacy laws HIPPA. Electronic therapy is the delivery of therapy services solely by electronic means (email, audio or visual) which allows the therapist and patient to be in separate physical locations during treatment. Though more convenient, electronic therapy may not be as thorough as traditional face to face therapy and if my therapist believes I would be better served with traditional therapy I will be provided with mental health specialists in my area. The electronic means of communication in electronic therapy is encrypted to prevent unauthorized access. I understand that electronic therapy involves technological risks that despite this encryption, may be breached by unauthorized users and my health information compromised. Patient Rights Patients have the right to decline or revoke consent to the use of electronic therapy at any time. I understand the information provided is protected by federal privacy laws except under certain circumstances where disclosure is required by law, such as the patient presenting a danger to himself or others. I agree to submit this evaluation on a secure internet connection not open to the public. *

Question 21. Since the traumatic event took place have you had difficulty meeting new people? *

Yes

Part II. General Mental and Physical Health -- Question 1. Major Life Events: Please list any major events that have been a significant source of stress or anxiety in your life during the last year. Sometimes major life events can cause symptoms similar to a psychological illness. For example, the death of a loved one can understandably have negative affects on one"s mental health. Emotions of grief, sorrow, and anxiety are not unusual in such a situation and does not necessarily mean you have an emotional disability. Please provide as much info as possible - in none please write none *

QUESTION 28. If you answered YES to the question above can you describe what kind of events you worry about and what happens to you when you worry. Please provide as many details as possible

Question 6. General Physical Health : How has your general Physical Health been in the last 12 months. Have you suffered from ANY major physical ailments including but not limited to :Heart Problems, Cancer(s), Diabetes, Organ Failure, Broken Bones, Fever, or Severe Head Aches. If so please explain, if not then please type "None" in the field below *

QUESTION 29. Do people ever say you worry about things too much? *

Yes

QUESTION 46. During a panic attack did you often feel dizzy or nauseous? *

Yes

Part VI (SSP) - Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. ------------------------ QUESTION 52. Do you have an intense fear that you will do or say something in front of others that will embarrass you? *

Yes

QUESTION 37. Do you often become tired easily or experience a sudden unexplained loss of energy? *

Yes

QUESTION 33. When worried do you frequently feel irritable or on edge for no apparent reason? *

Yes

Do you have any thoughts about harming yourself or others? And if so what methods would you use to do so? (If you answer yes to this question Please call your local Police for help immediately before proceeding with this exam). *

Date of Birth (must be over 18 years of age)

QUESTION 32. How long have you had difficulty controlling your worries in the past 12 months? *

None

Less than 30 days

One to three months

Three to six months

Over six months

QUESTION 36. When worried do you have tensions or muscle aches? *

Yes

Has your pet ever bitten anyone or exhibited aggressive behavior *

Yes

QUESTION 66. Have you lost interest in activities you previously enjoyed because of feelings of sadness or depression? *

Yes

QUESTION 65. Has your depression caused you to gain or lose a significant amount of weight (greater than 5%) in any given month? *

Yes

QUESTION 43. Do you often worry that you will experience more panic attacks in the future? *

Yes

Part III PTSD - Please write complete answers when requested and type Yes or No to all questions or write "Unsure" if you do not know. ----------------------- Question 9. Have you ever been exposed to a traumatic event in which your life or someone else"s was actually in danger or you thought your life or someone else"s was in danger? *

Yes

Question 15. Do you try to avoid conversations or thoughts that remind you of the traumatic event? *

Yes

Question 25. In the last 90 days how often have you been bothered by your emotions/symptoms from the traumatic event (Rarely, Moderately, Often, Very Often, or None of the Above)

Rarely

Moderately

Often

Very Often

None of the Above

Email: *

Question 8. Illicit Drug Use: If you use ANY drugs please identify the drug, the frequency of use and amount consumed. If none then please type "None" in the field below. *

Congratulations - You're Finished!! Please click "Submit" Below to Save and Submit Your Exam - You will then be taken to a Paypal page to complete payment. Your Evaluation will be saved after clicking "Submit" -----Thank You!!

Drug and Alcohol Use: Similar to Major Life Events sometimes symptoms of psychological problems can be caused by Illegal Drug use or excessive alcohol consumption. To better understand your current mental health condition please provide the following information. ------------------------------- Question 7. Alcohol If you have consumed alcohol in the last 12 months please list the frequency and amount consumed. If none then please type "None" in the field below. *

Part I *

Question 22. Do reminders of the traumatic event cause physical symptoms of distress, such as trembling, shortness of breath, increased pulse, muscle aches, or sweating? *

Yes

QUESTION 57. Does your fear prevent you from performing said activity in Question #53 or make the task extremely difficult completing?

Yes

Question 4. General Medical History: Please list ANY illness (psychological or physical) you have been diagnosed with. If none then please write "None" in the field below. Illness........................................................... Approximate Date of Diagnosis *

QUESTION 71. Do you often feel fidgety or have problems sitting still? *

Yes

QUESTION 70. Do you have difficulty sleeping or sleep too much? If so, in the last 3 months how often do you experience difficulty sleeping? On a daily basis (more frequently), several times each week (frequently), only a few times each month, or None *

Daily

Several times per week

A few times per month

None of the above

Question 26. Do the unwanted thoughts or feelings related to the traumatic event interfere with any major life activity (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.)

Yes

Question 11. Have you had recurrent unwanted recollections of the traumatic in last 6 months - including thoughts, dreams or perceptions? *

Yes

If you answered YES above please explain how your panic attacks interfere with your daily life activities. Please provide as much information as possible.

QUESTION 48. During your last panic attack did you have hot flashes or experience profuse sweating? *

Yes

QUESTION 58. Do you think you are more afraid or worried than you should be? *

Yes

QUESTION 45. During your last panic attack did you experience uncontrollable shaking or trembling? *

Yes

QUESTION 31. Do you have difficulty controlling your worries or anxiety? *

Yes

QUESTION 41. If you answered YES to the question above please describe your most recent panic attack, what happened? Please provide as much information as possible.

If you answered YES above please describe what happened and provide as much information as YOU ARE COMFORTABLE providing.

Question 13. Do you have intense feelings of distress or anxiety when reminded of the traumatic event? *

Yes

QUESTION 49. During your last panic attack did any of your extremities (legs, fingers, toes, ect.) feel numb? *

Yes

QUESTION 55. Before, during or immediately after the feared activity in question #53 do you experience any physical symptoms such as shaking, trembling, perspiring or nausea?

Yes

QUESTION 72. Do you often feel fatigued or suffer from an unusual loss of energy? If so how often do you experience fatigue? *

Daily

Several times per week

A few times per month

None of the above

Phone *

QUESTION 62. On a typical day how long do your feelings of sadness or depression persist? *

Less than one hour

One to three hours

Three to five hours

Greater than five hours

None of the above

If you answered YES above please (1) Describe your recurrent thoughts, dreams or perceptions (2) Frequency - How often have you experienced these recurrent thoughts, dreams, or perceptions during the last 6 months Please provide as much detail as you are comfortable providing.

Question 17. Since the traumatic event took place have you had difficulty concentrating? *

Yes

QUESTION 34. Do you often worry something bad is going to happen to you or someone close to you? *

Yes

QUESTION 68. Do you often have feelings of worthlessness or often experience low self esteem *

Yes

Question 5. Medications: Please list ANY medications that you are currently taking and the dosage if known. *

Question 3. Impact on Major Life Activities: Is there one or more major life activity that you are unable to perform (or have great difficulty performing) because of problems caused by stress or any other emotional problem? (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working). *

Yes

If you answered YES above please explain how the feared activity interferes with your daily life activities. Please provide as much information as possible.

If you answered Yes above, how frequently has your worrying caused anxiety or stress in the last six months on a daily basis(more frequently), several times each week(frequently), only a few times each month or less, or None)

None

Every Day

Several times per week

A few times per month

Question 23. Do you feel your future life may be negatively impacted as a result of the traumatic event? *

Yes

Mailing Address *

If You answered YES above please (1) List the major life activity you are unable to perform or have difficulty performing and how you feel it has been affected by the unwanted thoughts or feelings related to the traumatic event. (2) How long has this been occurring for - please list approximate dates and provide as much information as possible

QUESTION 53. If you answered YES to the question above please describe specifically what activity you are afraid of performing in front of other people that causes intense fear or anxiety. Please provide as many details as possible.

Preferred Emotional Support Pet (If more than 1 pet please contact us first) *

Dog

Cat

Other

Pet Breed and Approximate weight *

QUESTION 56. Have you ever completely avoided the activity in Question #53 because of fear or anxiety?

Yes

Question 20. Since the traumatic event took place are you less interested in activities you previously enjoyed? *

Yes

QUESTION 40. If you answered yes to #39 how often do these anxiety attacks occur - on a daily basis (more frequently), several times each week (frequently), only a few times each month, or None

Daily

Several times a week

A few times a month

None of the above

QUESTION 73. Do the unwanted feelings of sadness or depression interfere with any major life activity (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.) *

Yes

QUESTION 42. Do you often worry that these panic attacks will have negative health consequences - possible heart attack, losing control, or other debilitating affects? *

Yes

Question 16. Since the traumatic event have you been much more alert or looking out for possible trouble? *

Yes

QUESTION 50. During your last panic attack did you feel detached from reality, almost like you were dreaming? *

Yes

QUESTION 54. Does your fear in question #53 cause you intense stress or anxiety?

Yes

Question 12. Have you ever had flashbacks or feelings you were reliving the traumatic event even while you"re awake? *

Yes

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Question 24. Since the traumatic event took place have you had difficulties showing emotions of love or affection? *

Yes

If you answered Yes above please explain below (or leave blank if you answered No)

QUESTION 47. During your last panic attack did you have difficulty breathing or feel like you were out of breath? *

Yes

Question 10. Did you experience feelings of intense fear or helplessness after the event?

Yes

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If You answered YES above please (1) List the major life activity you are unable to perform or have difficulty performing and how you feel it has been affected by your emotional problems. (2) How long has this been occurring for - please list approximate dates and provide as much information as possible.

QUESTION 67. If you answered YES above, in the last 3 months how long has your disinterest in previously interested activities persisted for? Short term (one week or less); Mild (one week to two weeks), Moderate (two weeks to one month) Severe (more than one month) or None of the above. *

One week or less

One to two weeks

Two weeks to one month

More than one month

None of the above

QUESTION 44. During your last panic attack did you feel your pulse increase (increased heart rate)? *

Yes

QUESTION 61. If you answered yes to #60 how often have you felt sad or depressed in the last 30 days? On a daily basis (more frequently), several times each week (frequently), only a few times each month, or None

Daily

Several time per week

A few times per month

None of the above

Last Name *

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