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1/11
Psychological Evaluation for Long Term Treatment with Opioid Medication
Aloha! You've been referred by Dr. Tavares to receive a psychological evaluation. This is not an
assessment of your injury and\or pain. The purpose of this evaluation is to assess:
1) how effective you think your current medications are for treating your pain, and
2) your risk of experiencing any undesireable biopsychosocial consequences of your opioid medications.
This assessment entails completion of this assessment package (11 pages), plus 3 other forms that will be
given to you on your first visit. These 3 forms take patients an average of 20 minutes to complete. These forms
are designed to assess personality and mood and will be followed by a meeting with the psychologist. Please
have this intake package completed before your appointment to avoid a delay in your assessment.
Thank you for your patience. If you have any questions, please contact your provider at Aloha Counseling
Associates, LLC (ACA, LCC). Thank you for your help.
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]
2/11
PATIENT 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#:__________________________
HIPAA: I was offered a copy of the HIPAA form concerning privacy protection by a representative of
Aloha Counseling Associates, LLC.
__________________________________________
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]
3/11
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 Damien Tavares, M.D. 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]
4/11
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.
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.
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.
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.
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]
5/11
__________________________________________
Signature
___________________
Date
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 pain begin:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What things have you tried to deal with the pain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are you taking any medications on an ongoing basis? Yes/No
Name of Medication
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
How Long
____________
____________
____________
____________
____________
____________
Name of Prescribing Physician
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Please indicate if you have had any history of the following medical problems:
Head Injuries
Hearing/Ear Problems
Loss of Consciousness
Nightmares
Serious Accidents
Circle One
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Ages
_____
_____
_____
_____
_____
Describe
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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]
6/11
Thyroid Difficulties
Tics/Twitching
Vision/Eye Problems
Yes/No
Yes/No
Yes/No
_____ _______________________________________________
_____ _______________________________________________
_____ _______________________________________________
Alcohol Use/Abuse
Illicit Drug Use/Abuse
Risky Behaviors
Yes/No
Yes/No
Yes/No
_____ _______________________________________________
_____ _______________________________________________
_____ _______________________________________________
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
Verbal Abuse
Yes/No
Physical Abuse
Yes/No
Sexual Abuse
Yes/No
SCHOOL HISTORY
Graduated High School
Attended College
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: _________________________________________________
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: _____________________________________
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]
7/11
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
Position
____________________________
____________________________
____________________________
____________________________
Yrs Employed
__________
__________
__________
__________
When/Why: ___________________________________________
When/Why: ___________________________________________
When/Why: ___________________________________________
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: _____________________________
Yes/No
Yes/No
Yes/No
Who: _____________________________
Who: _____________________________
Who: _____________________________
NEXT PAGE PLEASE
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]
8/11
COMM™
Please answer each question as honestly as possible. Keep in mind that we are only asking about the past
30 days. There are no right or wrong answers. If you are unsure about how to answer the question,
please give the best answer you can.
Please answer the questions using the following scale:
Never = 0, Seldom = 1, Sometimes = 2, Often = 3, Very Often = 4
1. In the past 30 days, how often have you had trouble with thinking clearly or had memory problems?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
2. In the past 30 days, how often do people complain that you are not completing necessary tasks? (i.e.,
doing things that need to be done, such as going to class, work or appointments)
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
3. In the past 30 days, how often have you had to go to someone other than your prescribing physician to
get sufficient pain relief from medications? (i.e., another doctor, the Emergency Room, friends, street
sources)
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
4. In the past 30 days, how often have you taken your medications differently from how they are
prescribed?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
5. In the past 30 days, how often have you seriously thought about hurting yourself?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
6. In the past 30 days, how much of your time was spent thinking about opioid medications (having
enough, taking them, dosing schedule, etc.)?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
7. In the past 30 days, how often have you been in an argument?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
8. In the past 30 days, how often have you had trouble controlling your anger (e.g., road rage, screaming,
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]
9/11
etc.)?
NEVER = 0
SELDOM = 1
SOMETIMES = 2
OFTEN = 3
VERY OFTEN = 4
9. In the past 30 days, how often have you needed to take pain medications belonging to someone else?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
10. In the past 30 days, how often have you been worried about how you’re handling your medications?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
11. In the past 30 days, how often have others been worried about how you’re handling your
medications?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
12. In the past 30 days, how often have you had to make an emergency phone call or show up at the clinic
without an appointment?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
13. In the past 30 days, how often have you gotten angry with people?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
14. In the past 30 days, how often have you had to take more of your medication than prescribed?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
15. In the past 30 days, how often have you borrowed pain medication from someone else?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
16. In the past 30 days, how often have you used your pain medicine for symptoms other than for pain
(e.g., to help you sleep, improve your mood, or relieve stress)?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
17. In the past 30 days, how often have you had to visit the Emergency Room?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
©2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No
other uses or alterations are authorized or permitted by copyright holder. Permissions questions: [email protected].
The COMM™ was developed with a grant from the National Institutes of Health and an educational grant from Endo
Pharmaceuticals.
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]
10/11
SOAPP®-R
The following are some questions given to patients who are on or being considered for medication for
their pain. Please answer each question as honestly as possible. There are no right or wrong answers.
Please answer the questions using the following scale:
Never = 0, Seldom = 1, Sometimes = 2, Often = 3, Very Often = 4
1. How often do you have mood swings?
NEVER = 0 SELDOM = 1 SOMETIMES = 2
OFTEN = 3
VERY OFTEN = 4
2. How often have you felt a need for higher doses of medication to treat your pain?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
3. How often have you felt impatient with your doctors?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3
VERY OFTEN = 4
4. How often have you felt that things are just too overwhelming that you can't handle them?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
5. How often is there tension in the home?
NEVER = 0 SELDOM = 1 SOMETIMES = 2
OFTEN = 3
VERY OFTEN = 4
6. How often have you counted pain pills to see how many are remaining?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
7. How often have you been concerned that people will judge you for taking pain medication?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
8. How often do you feel bored?
NEVER = 0 SELDOM = 1 SOMETIMES = 2
OFTEN = 3
VERY OFTEN = 4
9. How often have you taken more pain medication than you were supposed to?
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]
11/11
NEVER = 0
SELDOM = 1
SOMETIMES = 2
OFTEN = 3
VERY OFTEN = 4
10. How often have you worried about being left alone?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3
VERY OFTEN = 4
11. How often have you felt a craving for medication?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3
VERY OFTEN = 4
12. How often have others expressed concern over your use of medication?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
13. How often have any of your close friends had a problem with alcohol or drugs?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
14. How often have others told you that you had a bad temper?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
15. How often have you felt consumed by the need to get pain medication?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
16. How often have you run out of pain medication early?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3
VERY OFTEN = 4
17. How often have others kept you from getting what you deserve?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
18. How often, in your lifetime, have you had legal problems or been arrested?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
19. How often have you attended an AA or NA meeting?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3
VERY OFTEN = 4
20. How often have you been in an argument that was so out of control that someone got hurt?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
21. How often have you been sexually abused?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3
VERY OFTEN = 4
22. How often have others suggested that you have a drug or alcohol problem?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
23. How often have you had to borrow pain medications from your family or friends?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
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]
12/11
24. How often have you been treated for an alcohol or drug problem?
NEVER = 0 SELDOM = 1 SOMETIMES = 2 OFTEN = 3 VERY OFTEN = 4
Comments:
©2014 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No
other uses or alterations are authorized or permitted by copyright holder. Permissions questions: [email protected].
The SOAPP®-R was developed with a grant from the National Institutes of Health and an educational grant from Endo
Pharmaceuticals.
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]