1. travel
2. transports
3. air travel
4. airlines

1/17
Psychological Evaluation for Implantable Device
Aloha! Welcome to Aloha Counseling Associates, LLC. Your doctor has referred you for a psychological evaluation. All
insurance companies require that a psychological evaluation be done prior to undergoing a trial with a spinal cord
stimulator or inthrathecal pump. The reason for this is to assess for any emotional or psychological issues that may affect
your response to treatment. You may be asked questions about your medical history, your emotional functioning, and your
emotional reaction to your pain. Many studies have shown that some psychological conditions may interrupt your body's
ability to benefit from an implantable device. If this evaluation identifies such conditions, your clinician will make
treatment recommendations to your referring physician before you can proceed.
This evaluation requires you to complete different assessment forms. Two of them are in this packet--WHY-MPI, and
PSQ (see below). On your first visit, you will be administered 3 more assessments. These assessments may take 30
minutes to complete and is followed by an intake with your provider. A second appointment might be needed if the intake
is not completed. Before coming to your appointment, please complete the forms in this packet and kindly bring them to
your appointment. Please plan ahead and pace yourself as these forms will take some time to complete.
1) Intake Form
2) West Haven-Yale Multidimensional Pain Inventory (WHY-MPI)
3) Pain Self Efficacy Questionnaire (PSQ)
If you have any questions or concerns, please contact us at 680-0558.
Sincerely,
Dr. Valdez and Staff
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
2/17
Welcome to Aloha Counseling Associates, LLC (ACA, LCC). We are looking forward to meeting with you.
Before your first appointment, we would like you to read and complete the following forms in this packet:
1) Demographic Information, 2) Insurance Information, 3) Professional Fees, 4) Late Cancellation/No
Show Policy, 5) Acknowledgement of HIPPA, 6) Release of Information, 7) Treatment Guidelines, 8) Consent for
Treatment, and 9) Adult History Form
If you have any questions, please contact your provider or staff at Aloha Counseling Associates, LLC (ACA, LCC).
Thank you for your help.
DEMOGRAPHIC INFORMATION
Full Name: _____________________________________________ Date of Birth: ________________
Race/Ethnicity: ____________________ Age: __________ Sex: Male/Female
Preferred Phone: _________________________ Home/Cell/ Work (circle one) ¨ Check if OK to leave message
Alternative Phone: _______________________ Home/Cell/ Work (circle one) ¨ Check if OK to leave message
Marital Status: □ Never Married □ Married/Committed Relationship □ Divorced □ Separated □ Widowed
I am presently living: □Alone □With others (please specify):_________________________________
Home Address:___________________________________________________________________________
Primary Care Physician: ___________________________________________________________________
Referred by (if different that PCP): ___________________________________________________________
INSURANCE INFORMATION
Primary Insurance Company: ___________________________ Subscriber #: ____________________________
Group #: _________________________
Sponsor SS# (Tricare Only) ______________________________
Secondary Insurance Company: _________________________ Subscriber #: ____________________________
Group#:__________________________
Signature: __________________________________________
Date: ____________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
3/17
ACKNOWLEDGEMENT OF HIPAA
I was offered a copy of the HIPAA form concerning privacy protection by a representative of Aloha Counseling
Associates, LLC or have downloaded the HIPPA form from the ACA, LCC website.
__________________________________________
Signature
___________________
Date
RELEASE OF INFORMATION
Patient Name: _____________________________________________________
Patient Date of Birth: ________________________________________________
Person Authorized to give permission: __________________________________
Relationship to patient: ______________________________________________
I give permission for the staff at Aloha Counseling Associates, LLC to communicate with
_______________________________________________________ (name of primary care provider) and exchange
information, if necessary, regarding medical and psychological information.
This information will be used for evaluation, treatment, or psychological consultation regarding the patient
listed above. The above permission includes oral communication and exchange of relevant patient
information, including but not limited to, summaries of treatment, copies of records, and diagnosis, when
necessary.
______________________________________________
Authorized Person Granting Permission
Signature
__________
Date
______________________________________________
Clinician Signature
__________
Date
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
4/17
TREATMENT GUIDELINES
Confidentiality:
In general, the privacy of all communications between a patient and a psychologist is protected by law, and your provider
can only release information about our work to others with your written permission. But there are a few exceptions.
(Your initials indicate that you read and understood each exception.)
Legal Proceedings: If, for some reason, your provider is court ordered to testify or release information regarding your
mental health or where your emotional condition is an important issue. Initials: ____
Abuse: If you tell your provider that you or some other identifiable person is abusing a child, elderly, or disabled person,
your provider is legally mandated to file a report with the appropriate state agency. Initials: _____
Danger To Self or Others: If you tell your provider that you are threatening serious bodily harm to either yourself or
another. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the
patient, or contacting family members or others who can help provide protection. Initials: _____
These situations occur quite rarely. But, if this situation occurs, your provider will make every effort to fully discuss it
with you before taking any action.
Minors: If you are a minor, under the age of 18, please be aware that the law may provide your parents the right to
information about your treatment. For teenagers, it is the policy at ACA, LLC to request an agreement from your parents
that they be provided with only general information about our work together, unless there is a high risk that you will
seriously harm yourself or someone else. Before giving them any information, your provider will discuss the matter with
you, if possible, and do their best to address any objections you may have.
Office Sharing: Please note ACA, LLC shares an office space with West Shore Neurological Services, LLC. These are
two separate entities, however, we consult with each other if you are a patient at both clinics.
PROFESSIONAL RECORDS
ACA, LLC is required to keep records of its professional services, your treatment, or your work together. Our general
policy is that patients may not review them; however, we can provide a treatment summary unless it is believed that doing
so would be emotionally damaging. If that is the case, we will be happy to send the summary to another mental health
professional who is working with you.
DISPUTES
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full
disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal
proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.) neither you nor your
attorney(s) nor anyone else acting on your behalf will call on ACA, LLC provider(s) to testify in court or at any
other proceeding, nor will a disclosure of psychotherapy records be requested.
(Please initial here): _____________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
5/17
CONSENT FOR TREATMENT
I authorize Dr. Jay Valdez, Psychologist at Aloha Counseling Associates, LCC, to provide
psychological evaluation and/or treatment to me. I have read and understood the forms in this
packet and agree to all its conditions.
__________________________________________
Signature
___________________
Date
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
6/17
PATIENT INFORMATION FORM
Please complete to the best of your knowledge. Leave blank to those you do not know answer to.
Thank You!
ADULT HISTORY
Patient Name: ________________________________ Today’s Date: ___________________________________
Form Completed by: ___________________________ Relationship: ____________________________________
Date of Birth: _________________________________ Race/Ethnicity: __________________________________
Referred by: __________________________________ Reason for Referral: ______________________________
Emergency Contact: ____________________________ Emergency Phone: _______________________________
PRESENTING PROBLEM
How long ago did the problem begin:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Reason(s) for seeking services:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What things have you tried to deal with these concerns:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MEDICAL HISTORY
Are you taking any medications on an ongoing basis? Yes/No
Name of Medication
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Dose/Frequency
____________
____________
____________
____________
____________
____________
Name of Prescribing Physician
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Medical Hospitalizations/Surgeries:(Please describe and include dates)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
7/17
Please indicate if you have had any history of the following medical problems:
Circle One
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Diabetes
Chronic Ear Infections
Headaches
Head Injuries
Hearing/Ear Problems
Loss of Consciousness
Nightmares
Serious Accidents
Sleep Apnea/Snoring
Surgeries
Thyroid Difficulties
Alcohol Use/Abuse
Illicit Drug Use/Abuse
Risky Behaviors
Ages
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Describe
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
MENTAL HEALTH
Please check any of the following stresses that apply to you or your family and describe:
□ Major Relocations:___________________________________________________________________________
□ Job Change:________________________________________________________________________________
□ Deaths:____________________________________________________________________________________
□ Marital/RelationalProblems:___________________________________________________________________
□ Someone Significant Moving Out of the Area:_____________________________________________________
□ Experiencing a Traumatic Event:________________________________________________________________
□ Witnessing a Traumatic Event: _________________________________________________________________
□ Child Protective Services (CPS) or Adult Protective Services (APS) Involvement: ________________________
____________________________________________________________________________________________
Circle One
Past Psychiatric Evaluation
Prior Diagnosis of a Mental Health Disorder
Prior Use of Psychiatric Medication
History of Harm to Self/Others
History of Suicide in Your Family
Past Psychiatric Hospitalization
HISTORY OF ABUSE
Emotional Abuse
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Date(s): _________________________________
Diagnoses: _______________________________
Name(s): ________________________________
Who/When: ______________________________
Who/When: ______________________________
Dates(s): _______________________________
Who/When: _________________________________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
8/17
Verbal Abuse
Physical Abuse
Sexual Abuse
Yes/No
Yes/No
Yes/No
SCHOOL HISTORY
Graduated High School
Attended College
Who/When: _________________________________________________
Who/When: _________________________________________________
Who/When: _________________________________________________
Yes/No
Yes/No
IMMEDIATE FAMILY HISTORY
Mental Health Illness
Substance Abuse
Legal Issues (Arrests/Jail)
Learning Difficulties/Disabilities
Name/Yr: _____________________________________________
Name/Yr: _____________________________________________
Yes/No
Yes/No
Yes/No
Yes/No
Diagnoses: _____________________________________
Type(s): _______________________________________
Type(s): _______________________________________
Diagnoses: _____________________________________
JOB HISTORY
Place of Employment:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
LEGAL HISTORY
Past Trouble with the Law
Gone to Court
Been Arrested
Yes/No
Yes/No
Yes/No
SUBSTANCE USE HISTORY
Past Use of Drugs or Alcohol
Use of Drugs or Alcohol Within Past Month
Past Treatment for Drugs/Alcohol
Addicted to Eating
Addicted to Gambling
Addicted to Spending Money
Addicted to Sex
Position
____________________________
____________________________
____________________________
____________________________
Dates
__________
__________
__________
__________
When/Why: ___________________________________________
When/Why: ___________________________________________
When/Why: ___________________________________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
SOCIAL RELATIONSHIPS
People are Supportive of You
You have People You Can Tell Personal Information
You have People to Do Things With
What/When: _____________________________
What/When: _____________________________
What/When: _____________________________
When: __________________________________
When: __________________________________
When: __________________________________
When: __________________________________
Yes/No
Yes/No
Yes/No
Who: _____________________________
Who: _____________________________
Who: _____________________________
HOW DO YOU DEAL WITH STRESS?
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
9/17
WEST HAVEN-YALE MULTIDIMENSIONAL PAIN INVENTORY
Kerns, Turk & Rudy (1985)
BEFORE YOU BEGIN, PLEASE ANSWER 2 PRE-EVALUATION QUESTIONS BELOW:
1. Some of the questions in this questionnaire refer to your “significant other”. A significant other is a person
with whom you feel closest. This includes anyone that you relate to on a regular or infrequent basis. It is very
important that you identify someone as your “significant other”. Please indicate below who your significant
other is (check one):
_ Spouse _ Partner/Companion _ Housemate/Roomate _ Friend _ Neighbor _ Parent/Child/Other relative
_ Other (please describe):
2. Do you currently live with this person? _ YES _ NO
When you answer questions in the following pages about “your significant other”, always respond in reference
to the specific person you just indicated above.
A. In the following 20 questions, you will be asked to describe your pain and how it affects your life. Under
each question is a scale to record your answer. Read each question carefully and then circle a number on the
scale under that question to indicate how that specific question applies to you.
1.Rate the level of your pain at the present moment.
No Pain 0 1 2 3 4 5 6 Very intense pain
2.In general, how much does your pain problem interfere with your day to day activities?
No interference 0 1 2 3 4 5 6 Extreme interference
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
10/17
3.Since the time you developed a pain problem, how much has your pain changed your ability to work?
No change 0 1 2 3 4 5 6 Extreme change
___ Check here, if you have retired for reasons other than your pain problem
4. How much has your pain changed the amount of satisfaction or enjoyment you get from participating in
social and recreational activities?
No change 0 1 2 3 4 5 6 Extreme change
5. How supportive or helpful is your spouse (significant other) to you in relation to your pain?
Not at all supportive 0 1 2 3 4 5 6 Extremely supportive
6. Rate your overall mood during the past week.
Extremely low mood 0 1 2 3 4 5 6 Extremely high mood
7. On the average, how severe has your pain been during the last week?
Not at all severe 0 1 2 3 4 5 6 Extremely severe
8. How much has your pain changed your ability to participate in recreational and other social activities?
No change 0 1 2 3 4 5 6 Extreme change
9. How much has your pain changed the amount of satisfaction you get from family-related activities?
No change 0 1 2 3 4 5 6 Extreme change
10. How worried is your spouse (significant other) about you in relation to your pain problem?
Not at all worried 0 1 2 3 4 5 6 Extremely worried
11. During the past week, how much control do you feel that you have had over your life?
Not at all in control 0 1 2 3 4 5 6 Extremely in control
12. How much suffering do you experience because of your pain?
Not suffering 0 1 2 3 4 5 6 Extreme suffering
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
11/17
13. How much has your pain changed your marriage and other family relationships?
No change 0 1 2 3 4 5 6 Extreme change
14. How much has your pain changed the amount of satisfaction or enjoyment you get from work?
No change 0 1 2 3 4 5 6 Extreme change
__ Check here, if you are not presently working.
15. How attentive is your spouse (significant other) to your pain problem?
No at all attentive 0 1 2 3 4 5 6 Extremely attentive
16. During the past week, how much do you feel that you’ve been able to deal with your problems?
Not at all 0 1 2 3 4 5 6 Extremely well
17. How much has your pain changed your ability to do household chores?
No change 0 1 2 3 4 5 6 Extreme change
18. During the past week, how irritable have you been?
Not at all irritable 0 1 2 3 4 5 6 Extremely irritable
19. How much has your pain changed your friendships with people other than your family?
No change 0 1 2 3 4 5 6 Extreme change
20. During the past week, how tense or anxious have you been?
Not at all tense or anxious 0 1 2 3 4 5 6 Extremely tense or anxious
B. In this section, we are interested in knowing how your significant other (this refers to the person you
indicated above) responds to you when he or she knows that you are in pain. On the scale listed below each
question, circle a number to indicate how often your significant other generally responds to you in that
particular way when you are in pain.
1. Ignores me.
Never 0 1 2 3 4 5 6 Very often
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
12/17
2. Asks me what he/she can do to help.
Never 0 1 2 3 4 5 6 Very often
3. Reads to me.
Never 0 1 2 3 4 5 6 Very often
4. Expresses irritation at me.
Never 0 1 2 3 4 5 6 Very often
5. Takes over my jobs or duties.
Never 0 1 2 3 4 5 6 Very often
6. Talks to me about something else to take my mind off the pain.
Never 0 1 2 3 4 5 6 Very often
7. Expresses frustration at me.
Never 0 1 2 3 4 5 6 Very often
8. Tries to get me to rest.
Never 0 1 2 3 4 5 6 Very often
9. Tries to involve me in some activity
Never 0 1 2 3 4 5 6 Very often
10. Expresses anger at me.
Never 0 1 2 3 4 5 6 Very often
11. Gets me some pain medications.
Never 0 1 2 3 4 5 6 Very often
12. Encourages me to work on a hobby.
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
13/17
Never 0 1 2 3 4 5 6 Very often
13. Gets me something to eat or drink.
Never 0 1 2 3 4 5 6 Very often
14. Turns on the T.V. to take my mind off my pain
Never 0 1 2 3 4 5 6 Very often
C. Listed below are 18 common daily activities. Please indicate how often you do each of these activities by
circling a number on the scale listed below each activity. Please complete all 18 questions.
1. Wash dishes.
Never 0 1 2 3 4 5 6 Very often
2. Mow the lawn.
Never 0 1 2 3 4 5 6 Very often
3. Go out to eat.
Never 0 1 2 3 4 5 6 Very often
4. Play cards or other games.
Never 0 1 2 3 4 5 6 Very often
5. Go grocery shopping.
Never 0 1 2 3 4 5 6 Very often
6. Work in the garden.
Never 0 1 2 3 4 5 6 Very often
7. Go to a movie.
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
14/17
Never 0 1 2 3 4 5 6 Very often
8. Visit friends.
Never 0 1 2 3 4 5 6 Very often
9. Help with the house cleaning.
Never 0 1 2 3 4 5 6 Very often
10. Work on the car.
Never 0 1 2 3 4 5 6 Very often
11. Take a ride in a car.
Never 0 1 2 3 4 5 6 Very often
12. Visit relatives.
Never 0 1 2 3 4 5 6 Very often
13. Prepare a meal.
Never 0 1 2 3 4 5 6 Very often
14. Wash the car.
Never 0 1 2 3 4 5 6 Very often
15. Take a trip.
Never 0 1 2 3 4 5 6 Very often
16. Go to a park or beach.
Never 0 1 2 3 4 5 6 Very often
17. Do a load of laundry.
Never 0 1 2 3 4 5 6 Very often
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
15/17
18. Work on a needed house repair.
Never 0 1 2 3 4 5 6 Very often
Source: Kerns, R.D., Turk, D.C., & Rudy, T.E. (1985). The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain, 23,
345-56.
Reproduced with permission
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
16/17
PAIN SELF EFFICACY QUESTIONNAIRE (PSEQ)
M.K.Nicholas (1989)
NAME: __________________________________________ DATE: __________________
Please rate how confident you are that you can do the following things at present, despite the pain. To indicate
your answer circle one of the numbers on the scale under each item, where 0 = not at all confident and 6 =
completely confident.
Remember, this questionnaire is not asking whether of not you have been doing these things, but rather how
confident you are that you can do them at present, despite the pain.
1. I can enjoy things, despite the pain.
Not at all 0 1 2 3 4 5 6 Completely confident
2. I can do most of the household chores (e.g. tidying-up, washing dishes, etc.), despite the pain.
Not at all confident 0 1 2 3 4 5 6 Completely confident
3. I can socialise with my friends or family members as often as I used to do, despite the pain.
Not at all confident 0 1 2 3 4 5 6 Completely confident
4. I can cope with my pain in most situations.
Not at all confident 0 1 2 3 4 5 6 Completely confident
5. I can do some form of work, despite the pain. (“work” includes housework, paid and unpaid work).
Not at all confident 0 1 2 3 4 5 6 Completely confident
6. I can still do many of the things I enjoy doing, such as hobbies or leisure activity, despite pain.
Not at all confident 0 1 2 3 4 5 6 Completely confident
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
17/17
7. I can cope with my pain without medication.
Not at all confident 0 1 2 3 4 5 6 Completely confident
8. I can still accomplish most of my goals in life, despite the pain.
Not at all confident 0 1 2 3 4 5 6 Completely confident
9. I can live a normal lifestyle, despite the pain.
Not at all confident 0 1 2 3 4 5 6 Completely confident
10. I can gradually become more active, despite the pain.
Not at all confident 0 1 2 3 4 5 6 Completely confident
Source: Nicholas M.K. Self-efficacy and chronic pain. Paper presented at the annual conference of the British
Psychological Society. St. Andrews, 1989.
Reprinted with permission from the author
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]