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Patient Forms
New Patient Packet
psychiatry
counseling
dr. raja Ages 11-below
to be filled out by child
to be filled out by parent
Dr. raja ages 12-above
to be filled out by child
to be filled out by parent
Release of Information
HIPAA Form
PHQ-9
Snap Parent & Teacher Rating Scale
Change of Provider Form
Our Services
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Spravato
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Self-Assessments
About Us
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Locations
Attention Deficit Hyper-activity Disorder Questionnaire
ADHD Quiz
Introduction
1.
Do you tend to avoid or delay getting started on a new important task?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
2.
Do you find that the majority of your tasks (work/school assignments, etc.) are boring or repetitive, making them difficult to complete?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
3.
Do you find yourself making careless mistakes when engaged in something you feel is boring, repetitive, or difficult?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
4.
How often do you feel restless or fidgety?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
5.
Do you regularly fail to remember important appointments or obligations?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
6.
Do you have difficulty unwinding or feel often on the go?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
7.
Do you have difficulty concentrating on people when they are speaking to you?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
8.
Do you frequently misplace things (or have difficulty finding them)?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
9.
Are you typically distracted (or find it hard to focus) when there is activity or noise around you?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often
10.
Do you find yourself avoiding situations like waiting your turn in line when waiting is expected and appropriate (i.e. at the grocery store)?
*
This question is required.
Never
Rarely
Sometimes
Often
Very Often