EmailMe Form - Dr. Kinsora - Intake Form

Your first name. *

Your last name. *

Age. *

Your date of birth. *

Handedness *

Best phone number to reach you at (preferably a cellular phone) *

If you are filling this form out for the examinee (the person to be tested), what is your relationship with the examinee?

If you are not the examinee (the person to be tested), are you the patient's legal guardian?

YES

NO

Does not apply because I am the person being evaluated.

Who referred for neuropsychological assessment? *

You are ready to begin the intake!

PLEASE READ THESE DIRECTIONS ENTIRELY BEFORE STARTING

DO NOT ATTEMPT TO COMPLETE THIS ON YOUR PHONE! It will not work. There are twelve pages. This form will take 30 minutes or more to complete. Try to finish the form in ONE SITTING.

If you wish to take a break, wait until you get to the bottom of the page and click "Save and Resume Later". This will give you a link that you must copy down so that you can work on it later. Once you complete the entire questionnaire, click the "SUBMIT THIS FORM" button at the bottom of the last page. We will review this information with you on the day of your appointment.

If for some reason your browser stops and you have to start again, don't worry, everything you did is saved.  If this happens, just start a new form again, and complete some of the mandatory fields. Then just skip all of the questions that you already answered earlier, and continue where you left off. We can piece the two forms together and it will work out fine.

Thank you for assisting us! We look forward to talking to you in person.

Regarding this form and Private Health Information

The information that you enter on this intake form goes to a secure server where the information is stored. The server is fully HIPAA certified and complies with the technical safeguard section of the HIPAA security rule. For example, the server has passed Level 2 PCI certification, which is high level security requirement necessary to protect private information. The servers SSL certificates support high-grade 256-bit encryption. This online intake is being offered as a convenient option to the hand written form. If you decide that you would rather have the hand written form, please contact our office at 702 382-3670. We would be happy to send you a copy to fill out by hand.

1. I understand the fact that the present questionnaire is HIPAA certified and that even with the best encryption, there are always risks associated with sending personal health information over the internet. *

YES I agree to terms 1, 2, and 3.

Ground Rules

LIMITS TO CONFIDENTIALITY
The assessment that you have been referred for may be more detailed and comprehensive than any evaluation that you have experienced. It will take an entire day, but most people find it fun and challenging.

The tests that you will be taking are related how well your brain is processing information. You may be asked to do things such as remember stories, put together blocks to make designs, hold numbers in your mind, and respond rapidly to letters on a computer screen. We may test your ability to solve conceptual problems, and may test your ability to answer questions about the world. On some tasks you may need to go as fast as you can, and on others you are only required to be as accurate as possible. We may measure finger-tapping speed, fine motor skills, and grip strength. May test your sense of smell. We may ask about anxiety, depression and other emotional symptoms that you have. Most tests are only several minutes long, but there are a lot of them to complete during the day that you are with us. We will give you breaks and you are welcome to take snacks with you.

Foreseeable Risks, Discomforts, and Benefits: The vast majority of examinees find the assessment challenging, and intriguing. Some call the tests that we administer "fun". Either way the tests can be challenging, and you will need to really use your brain power to do well on them. Rarely, neuropsychological examinations can cause temporary fatigue, frustration, and anxiety. We will try to make this an enjoyable experience for you.

ILLNESS: If you wake up on the day of the examination and are clearly ill, or you know that you are ill in the days before the exam, please do not come in. Call us immediately (702 382-3670) and let us know that you are ill and we will reschedule you as soon as we can over the coming weeks.

RULES: - Below are some important rules that we have for you to follow.

Rule 1: Be honest and forthright when answering the questions below and when you come in for the examination: Some of the questions on this intake are highly personal. However, research clearly tells us that we are complex beings that are affected by our life experiences, our educational history, our social history, and our medical history. This is why people heal at different rates from injuries, and react in different ways to trauma. We can understand you best when we understand the overall system from which you came and the system in which you live presently. For this reason, it is important to be as honest and up front as possible when completing this questionnaire.

When you come in to complete the testing, remember to work hard and try your best on everything. If you are not motivated, or simply give up on the harder tests, we will not get an accurate reading of your cognitive processing. If at any time during the upcoming assessment you feel ill, or for any reason are not operating at the normal level or your current abilities, please let us know and we can either take a break or reschedule the assessment.

Rule 2: RECORDING AND TAKING NOTES ARE STRICTLY FORBIDDEN. We are required by law to protect the security of the tests that we administer (Nevada Administrative Code 641.234). Our ethical guidelines also demand that we make every attempt to protect the test material from release to anyone not licensed to possess them. In an effort to keep our legal and ethical obligations, and preserve the validity of the measures, we strictly forbid any type of recording (audio, video, photography, live feed, across cellular or other transmission device, and others), direct or indirect observation, and any type of note-taking during the assessment day. We also ask that you agree to never discuss the specific contents of any of the tests that we administer, to anyone (for example the words on a memory test or specific questions on an IQ test).

Rule 3: Absolutely no one other than the examinee, Dr. Kinsora, and Dr. Kinsora's staff members are allowed in the room during the evaluation.

Email

I have read, understand and agree to fully abide by all of the conditions and rules outlined above *

YES

While we understand that some of the people we evaluate commonly use alcohol, cannabis, and other recreational substances, we recommend that you take a break from these substances at least seven full days prior to your evaluation. It could affect the results. For this reason, we ask that you agree to this rule:

I agree to refrain from the use of any type of medication, alcohol, cannabis products (even if prescribed), or recreational substances, other than my prescription non-cannabis medications for at least seven full days prior to my evaluation. (Over-the-counter pain relievers are fine. Similarly, over-the-counter sleep aids can be used the night before the evaluation.) *

YES

No; I will NOT agree to the conditions or have more questions before answering (If so stop immediately and Contact Dr. Kinsora's office at 702 382-3670)

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