ADULT FORM

Expert Psychological AssociatesPY8016

George Zaky, Psy.D., LMHC, LLC
Florida Licensed Psychologist Lic # PY8016

www.DrGeorgeZaky.com

Clinical, Forensic and Neuropsychological Services
Clinical, Forensic and Neuropsychological Services
ADULT FORM
I, the consultee/undersigned (hereafter referred to as "Client"), the office of Dr. Zaky (hereafter referred to as "Office"), understand and agree to the following: I have been referred for a consultation by an agency (or self-referral) for the purpose of consultation, which may include diagnostic evaluation to assist DDD/QTC/VR/Court/FPL, or any other referral entity or on my directive. Limitations of Authority: I understand that Office does not have the authority to make the final determination (i.e., approval/denial) in cases of SSDI/ benefits or any benefits Client is applying for with any entity. Confidentiality: I understand that the information shared with the doctor or staff during the consultation will be relayed to the referring agency/entity in a report and not to Client (unless self-referral). Due to the nature of the consultation, no doctor-patient relationship would exist, and if Client wishes to obtain a copy of the consultation report or has question(s) about the consultation/report, Client and or their representative must contact the referring agency/entity directly. I agree that no report(s) or opinions will be shared by the doctor/staff directly with Client or their representative. Surveillance Cameras are used to deter crime and protect the safety and security of staff and Client. Surveillance cameras (in PSL office) are used upon walking into the building, conference rooms, and testing rooms. The cameras do not capture audio but rather video. Images obtained must be retained for a length of time, and they are NOT monitored by a monitoring company (only in the PSL office). Office do not have control over surveillance cameras used in satellite offices (e.g., WPB, BB, BG) used by Office. Unless such images have historical value or are being used for any investigation, their storage may be extended. Client agrees that no one is permitted to take pictures, audio/video recordings of tests, or interviews during the session without the written consent of this office, and only Dr. Zaky can authorize. Imminent Danger: I understand that if Dr. Zaky believes that there is imminent danger of Client's self-harming or harm to others, then the doctor/staff must act in informing the authorities/agencies/entities and pursue involuntary commitment/Baker Act to protect the claimant/others. Ownership and Use of Form and Content: I acknowledge that this form and its content are owned by Office, and it is not to be copied, photographed, or multiplied in any way. Communication: I (Client) authorize interactions/communication via phone calls, text, email, telehealth, letters, or any other means of communication for the purpose of confirming appointments, inquiries, or any other communication related to this consultation. I understand that your carrier may apply standard messaging and data rates and that Client is responsible for any fees associated with texts or other forms of communication by Client's phone carrier or any other fees. Cancelation/discontinuation of services: I (Client) understand that if I decide that I no longer wish to pursue releasing Client's report to the referring agency/entity, I must inform Office in writing and within a reasonable time before my scheduled appointment. If I fail to keep the confirmed appointment or wish to withdraw my participation or consent, Client is responsible for the total fees of the encounter, which may vary depending on the nature of the consultation and can range from several hundred dollars to thousands of dollars. HIPAA: I (Client) understand that Office must comply with the Health Insurance Portability and Accountability Act (HIPAA), a federal law that protects the privacy and security of personal health information. The office of Dr. Zaky is committed to protecting the privacy and security of my personal health information. I (Client) understand that Office will take appropriate measures to protect my personal health information from unauthorized access, disclosure, or use.

Telehealth: to ensure that you receive the care you need, our practice is offering telehealth services as an alternative to in-person visits. We want you to know that your privacy and security are our top priorities. Our telehealth platform complies with all applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA). This means that we make efforts to keep your telehealth consultation private, secure, and confidential, just like an in-person visit. However, we cannot guarantee breaches. We recommend that you find a quiet, private space for your telehealth appointment to ensure the confidentiality of your medical information. Please also make sure to log in to your telehealth appointment from a secure device and network and log in 10 minutes before your scheduled appointment.
Please take a CLEAR photo or your Driver's License/ID *
Signature*

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Patient’s Signature
Did you require any assistance completing this form?*
It is perfectly okay to have someone help you fill out this form
Please explain why you needed help filling out this form and who helped you (mom, dad, caregiver, etc.
Please be specific in your explanation
Please provide the date you completed this form.*

MonthDayYear
Please provide the date and time of your appointment with Dr. Zaky
Patient Name*

PrefixFirst NameLast Name
Name of parent/guardian (if you are a minor or with guardian oversight):

PrefixFirst NameLast Name
Last 4 of your SS#
Birth Date*

MonthDayYear
Age*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*
Email
example@example.com
Phone Number*

Area CodePhone Number
Handedness *
Marital Status*
Who do you live with?*
How many children do you have?*
Where were you born*

FloridaNew YorkNew JerseyCaliforniaOther
Who raised you?*
Did you experience childhood developmental delay/problems? *
Please explain childhood developmental delays/problems you may have had.
ex: walked or talked late, had childhood surgeries, etc.
Have you had developmental therapies growing up?

PhysicalSpeechOccupationalABANoneOther
Have you experienced any childhood abuse?
I identify myself as
EDUCATION
What is the highest grade completed?*
What year did you graduate or stop high school?*
What is the name of your high school?
Where was your high school or college?
Please provide city and state
Were you ever enrolled in "special education" or ESE?*
Please explain/describe your "special education" or ESE.
What kind of student were you in school?
Have you had any of the following help/plans in school?

NONEIndividual Education Plan (IEP)504 PlanExtra time for testingExtra tutoringPreferred seatingOther
Did you have behavioral problems in school?*
List any behavior problems you had growing up?*

NONEExcessive tardinessGang activitySuspensionExpulsionFightingSetting firesHurting or killing animalsStealingDefiantArgumentativeProblems with the lawBreaking into structuresRunning away from homeusing weapons to threaten/harm othersOther
Please explain college or job training you may have had after leaving high school:
ex: college, trade school, apprenticeship, etx.
DAILY ACTIVITIES
Do you need assistance with any of the following tasks:*

NONEDressingLaundryBathingCleaningKeeping appointmentsCookingUsing kitchen appliancesDrivingGroomingUsing public transportationOther
Why do you need assistance with the above tasks & what are your limitations?
Please be as specific as you can in your description
How did you arrive to our office today?*

Telehealth/Video/Audio SessionI droveSomeone drove meTaxi/BusWalk/BikeTelehealth/Video/Audio SessionOther
Do you have a valid driver’s license?*

YesNoOther
Do you have problems driving?*

NoYesOther
Please explain your driving problems *
WORK HISTORY
Are you employed?*

NoYesOther
If you are employed, where do you work and what do you do?
If you don't work, why can't you work?
Have you ever been fired or asked to leave a job?*
Please provide details as to why you were fired or asked to leave a job.*

List your most recent work history:*

	Employer Name	Type of Work	How long did you stay at this job	Were you fired?	Dates you were employed
Most recent job 1

LEGAL HISTORY
Were you ever arrested or had troubles with the law?*
Please explaine the reasons for your past arrests and or legal troubles.
Are you a convicted felon?
SUBSTANCE ABUSE HISTORY
Do you drink alcohol regularly?*
Have you EVER overused alcohol?*
When did you last abuse alcohol?
ex: 2019
Have you ever experienced alcohol-related blackouts or problems?*
Have you ever been charged with DUI? *
Have you EVER used recreational drugs or perscription medication(s) that was not prescribed to you? *
What kind of recreational drugs have you used?
When did you last use recreational drugs or medications that was not prescribed to you?
How often do you use recreational drugs?
List your drug(s) of choice
Do you use nicotine (e.g., cigarettes/E-cigarettes) products?*

YesNoOther
HEALTH AND SOCIAL INFORMATION
When was your last medical examination ?*
ex: 2019
What were the RESULTS of your last medical examination and the recommended treatment(s), if any?*
MEDICAL CONDITIONS
Do you have ONGOING medical issues?*
Please select any medical conditions you have

AsthmaAutoimmuneBlood diseaseHigh BloodLow BloodCancerDiabetesDizzinessEating DisorderEndocrineHIV/AIDSHepatitisHeart DiseaseHearing DisorderBone DisorderStrokeBrain InjuryChronic PainComaKidney DiseaseVision ProblemsSleep ProblemsAppetite ProblemsOther
Do you require any of the following assistive devices?*

NONEWalkerCaneWheelchairMotorized scooterHearing aidsCrutchesMagnifiers for readingTalking devicesText-to-speech deviceShower chairModified vehicleOther
Are the assistive device(s) prescribed by a healthcare provider?
Psychiatric Medications
Do you CURRENTLY take Mental Health medications?*
Please list your CURRENT Mental Health medications:
List PAST Mental Health medication(s) you took:
Who prescribed your Mental Health medications?

Primary Care Physician (PCP)PsychiatristNurse PractitionerPhysician AssistantOther
Do you take your Mental Health medications daily/as prescribed?
Why don’t you take your medications daily/as prescribed?
MENTAL HEALTH
What type of psychiatric/psychological services do you receive now?*

Therapy/CounselingMedicationsBothNoneOther
Are you currently receiving psychiatric/psychological services?*
Have you ever been diagnosed with a mental condition (e.g., depression, anxiety, bipolar, schizophrenia, etc.?*
Have you been experiencing recent mental health problems?*
What mental condition have you been diagnosed with?*

SchizophreniaBipolarMajor DepressionPanic AttacksPTSDSevere AnxietyHallucinationsDelusionsParanoiaAntisocial Personality DisorderBorderline Personality DisorderBorderline Intellectual FunctioningIntellectual DisabilityAutism Spectrum DisorderAsperger's syndromeDementiaTraumatic Brain Injury (TBI)Suicide ThoughtSuicide AttemptsBaker ActPsychiatric HospitalizationNONEOther
Within the past 6 months, have you experienced any of the following?*

DepressionIsolatingCryingGuiltLoss of interestsadnessAnxietyEmptinessHopelessnessWorthlessFatigueSuicide thoughtsNONEOther
Tell us more about your DEPRESSION (e.g., when did your depression start, end, what makes you depressed, what do you do when depressed, etc)?
MOOD DISTURBANCE:

GrandiosityPressured SpeechRapid SpeechRacing ThoughtsExcitabilityPoor JudgmentFeeling overly happy or "high" for long periods of timehaving a decreased need for sleeptalking very fast, often with racing thoughtsfeeling extremely restless or impulsivebecoming easily distractedhaving overconfidence in your abilitiesOther
Tell us more about your MOOD DISTURBANCE (e.g., when did your mood disturbance start, end, what disturbs your mood, what do you do when you experience mood disturbance, etc)?
History of major TRAUMA:

Recurrent Dreams of the traumaAvoidance of situations that remind you of the traumaRepeated, disturbing memories, thoughts, or images of a stressful experience from the pastRepeated, disturbing dreams of a stressful experience from the pastFeeling very upset when something reminded you of a stressful experience from the pastHaving physical reactions (e.g., heart pounding,trouble breathing, or sweating) when something reminded you of a stressful experience from the pastAvoiding thinking about it, avoiding activities or situations because they remind you of the traumaTrouble remembering important parts of a stressful experience from the pastFeeling distant or cut off from other people or emotionally numbBeing “super alert” or watchful on guardOther
Share more about your PSYCHOLOGICAL TRAUMA (e.g., when did your trauma start, end, what triggers your trauma symptoms, what do you do when you experience the trauma symptoms, etc)?
PANIC ATTACKS:

felt moments of sudden terror, fear or fright, sometimes out of the bluefelt anxious, worried, or nervous about having more panic attackshad thoughts of losing control, dying, going crazy, or other bad things happening because of panic attacksfelt a racing heart, sweaty, trouble breathing, faint, or shakyfelt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleepingavoided, or did not approach or enter, situations in which panic attacks might occurleft situations early, or participated only minimally, because of panic attacksspent a lot of time preparing for, or putting off, situations in which panic attacks might occurdistracted myself to avoid thinking about panic attacksNONEOther
Explain more about your PANIC ATTACKS (e.g., when did your attacks start, end, what triggers your panic symptoms, what do you do when you experience the attacks, etc.)?
Do you experience attention and concentration problems?
Attention and Concentration Problems (check all that applies)

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.Often has trouble holding attention on tasks or play activities.Often does not seem to listen when spoken to directly.Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).Often has trouble organizing tasks and activities.Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a longperiod of time (such as schoolwork or homework).Often loses things necessary for tasks and activities (e.g. school materials, pencils,books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).Is often easily distractedIs often forgetful in daily activities.Often fidgets with or taps hands or feet, or squirms in seat.Often leaves seat in situations when remaining seated is expected.Often runs about or climbs in situations where it is not appropriate (adolescents oradults may be limited to feeling restless).Often unable to play or take part in leisure activities quietly.Is often “on the go” acting as if “driven by a motor”.Often talks excessively.Often blurts out an answer before a question has been completed.Often has trouble waiting their turn.Often interrupts or intrudes on others (e.g., butts into conversations or games)Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities).There is clear evidence that the symptoms interfere with, or reduce the quality of,social, school, or work functioning.
Have you ever felt or been diagnosed with Autism or Asperger's?*
Have you been experiencing any of the following symptoms since childhood till now?

Difficulty interpreting what others are thinking or feelinTrouble interpreting facial expressions, body language, or social cuesDifficulty regulating emotionTrouble keeping up a conversationDifficulty maintaining the natural give-and-take of a conversationTendency to engage in repetitive or routine behaviorsOnly participates in a restricted range of activitiesStrict consistency to daily routines; outbursts when changes occurDeep knowledge of one particular topic, such as a certain branch of science or industryYou’ve always wanted a best friend, but never found oneYou often invent your own words and expressions to describe thingsYou follow the same schedule every day of the week, and don’t like unexpected eventsExpressions like, “Curiosity killed the cat” or “Don’t count your chickens before they hatch” are confusing to youIn your leisure time, you prefer to play individual games and sports, like golf, where everyone works for themselves instead of working toward a common goal on a teamOther
Have you ever spent the night at a mental health facility?*
Share information about your mental health hospitalization:
ex: how many times you were admitted, when, where, and why
Other symptoms:

HallucinationsParanoiaOut of body experiencesDelusionsMemory problemsConcentration problemsObsessive thoughtsSelf injury behaviorSuicide attemptsPsychiatric hospitalizationsFamily mental health problemsOther
Have you ever been admitted to a psychiatric facility (voluntarily or Baker Act)?
Please tell more about your psychiatric hospitalization (e.g., when, where, duration, why, etc.:
Do you have a FAMILY history of mental illness?*
Tell us about your FAMILY history of mental illness (diagnosis, who was diagnosed, etc.):
Can you manage (budget, save, spend appropriately) your finances without help?*
Why can't you manage your finances? (please explain why and who helps you now, if any):
1. Have you ever felt you should cut down on your drinking?*
2. Have people annoyed you by criticizing your drinking? *
3. Have you ever felt bad or guilty about your drinking? *
4. Have you ever had a drink first thing in the morning to steady your nerves or toget rid of a hangover (eye-opener)? *
Additional comments
Please rate your experience in completing this form.
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Expert Psychological AssociatesPY8016

Clinical, Forensic and Neuropsychological Services

ADULT FORM

Patient’s Signature

EDUCATION

DAILY ACTIVITIES

WORK HISTORY

LEGAL HISTORY

SUBSTANCE ABUSE HISTORY

HEALTH AND SOCIAL INFORMATION

MEDICAL CONDITIONS

Psychiatric Medications

MENTAL HEALTH