Psychological Assessment Intake Effective 2023-07-13

1
What led you to seek an assessment/diagnosis at this time?* This field is required.Select all that apply
Curious for my own knowledge
Need a diagnosis to get medication
School accommodations
Work accommodations
Need a diagnosis to get into a treatment program
Healthcare Provider requested assessment
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Before proceeding, please acknowledge that we do not offer assessments for the following reasons:* This field is required.* Psychoeducational assessments: For IQ, learning or developmental disabilities, giftedness, etc. * Capacity assessments: To assess important life decision-making ability * Legal / court reasons * Medical legal assessments (e.g., for motor vehicle accidents) * Custody / parenting evaluations * Government benefits / tax reasons (e.g., ODSP, Developmental Services) * Third-party disability applications (e.g., WSIB, Canada Life)
I acknowledge that I am not seeking an assessment for any of the reasons listed above
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Extended Health Benefits Coverage

The cost of the assessment is covered by extended health benefits. If you want to submit a mock receipt to your insurance company for a coverage estimate, you can find a receipt breakdown on our FAQ Page
4
What is the main area(s) you are looking for clarification on at this time?* This field is required.We only provide assessment for the issues specified; for all others (e.g., Autism Spectrum Disorder, Neurocognitive Disorders, Psychotic Disorders) please speak with your primary health care provider. If you are unsure what type of issue you are coping with, please reach out to assessments@layla.care who can help you determine if this assessment is right for you.
ADHD (Attention Deficit Hyperactivity Disorder)
Anxiety issue and/or panic
Obsessive Compulsive Disorder (OCD)
Phobias
Bipolar Disorder
Depression, sadness, low mood, “numb” mood, lack of interest in things that used to be pleasurable, change in mood
Trauma
Psychological concerns related to physical health (e.g., worrying about having a serious illness, frequently focusing on physical symptoms, such as pain)
Borderline Personality Disorder
5
Layla is not a crisis service (For other crisis resources click here)* This field is required.If you experience a crisis or emergency between sessions, please call 911 or go to the nearest emergency room.
I understand and agree
6
(Deactivated on July 24 2:45 pm) What is the main area(s) you are looking for clarification on at this time?* This field is required.We only provide assessment for the issues specified; for all others (e.g., Autism Spectrum Disorder, Neurocognitive Disorders, Psychotic Disorders) please speak with your primary health care provider. If you are unsure what type of issue you are coping with, please reach out to contact@layla.care who can help you determine if this assessment is right for you.
ADHD (Attention Deficit Hyperactivity Disorder)
Anxiety issue and/or panic
Obsessive Compulsive Disorder (OCD)
Phobias
Bipolar Disorder
Depression, sadness, low mood, “numb” mood, lack of interest in things that used to be pleasurable, change in mood
Relationship/Personality
Trauma
Psychological concerns related to physical health (e.g., worrying about having a serious illness, frequently focusing on physical symptoms, such as pain)
7
What type of Assessment are you looking for? Please note, we currently only offer Diagnostic Assessments.* This field is required.Diagnostic: For ADHD, trauma, mood, anxiety, chronic pain/illness, and/or BPD. Psychoeducational: For IQ, learning or developmental disabilities, giftedness, etc. (Not available) Capacity: To assess important life decision-making ability. (Not available)
I am looking for a Diagnostic Assessment (for ADHD, trauma, mood, anxiety, chronic pain/illness, and/or BPD)
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SF Integration Field - What type of Assessment are you looking for?* This field is required.Diagnostic: For ADHD, trauma, mood, anxiety, chronic pain/illness, and/or BPD Psychoeducational: For IQ, learning or developmental disabilities, giftedness, etc. Capacity: To assess important life decision-making ability
Diagnostic
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Age acknowledgement (please read below)* This field is required.We are currently able to assess individuals of the following ages: * 16-65 in Ontario * 6+ in Alberta (please note we unable to do testing for cognitive decline) If you are looking for Borderline Personality Disorder assessment, you must be at least 18 years old. We will be continuing to expand our reach as we continue to grow this program!
I acknowledge that I am within the age for the main area I'm looking for clarification at this time
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How much are the symptoms you’re looking for clarification about impacting your day-to-day (mood, relationships, work, health)?* This field is required.
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
11
How long have you been dealing with these challenges?* This field is required.
Recently (one month or less)
Within 1-6 months
6-12 months
12+ months
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Name* This field is required.
First Name
Last Name
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Home Address* This field is required.Please share the address where you currently reside/will reside at the time of the assessment. This is important because our psychologists can only serve people residing in certain provinces.
Street Address
Street Address Line 2
City
Please Select
Please Select
ON
AB
Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Province age group (hidden for calculation)
16 - 65
18 - 65
6+
15
What is your date of birth?* This field is required.As previously acknowledged, we are currently able to assess individuals of the following ages: * 16-65 in Ontario * 6+ in Alberta (if you are over the age of 65, we are currently unable to perform cognitive testing) If you are looking for Borderline Personality Disorder assessment, you must be at least 18 years old. We will be continuing to expand our reach as we continue to grow this program!
Please type in the following format YYYY-MM-DD or select the date from the Calendar icon
Year
Month
Day
16
Today's Date
Date
Year
Month
Day
17
Age (Years)
18
Is ineligible due to province and age (hidden for condition logic)
Yes
19
Is ineligible for age and BPD (hidden for condition logic)BPD = Borderline Personality Disorder
Yes
20
We're Sorry!

At this time, we are unable to assess individuals of your age in {homeAddress:state}. We apologize for any inconvenience this may cause. Please check back later or contact our support team at assessments@layla.care for further assistance.
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We're Sorry!

At this time, we are unable to assess individuals below the age of 18 for Borderline Personality Disorder. We apologize for any inconvenience this may cause. Please check back later or contact our support team at assessments@layla.care for further assistance.
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What are your pronouns* This field is required.
She/her/hers
He/him/his
They/them/theirs
Other
23
Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
25
Emergency Contact* This field is required.Please provide name, phone, email, and relationship to you The emergency contact will only be used if there is a concern for your safety. Your privacy is our priority, and we will handle this information with the utmost care.
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What is the name of your Family Doctor?Skip if not applicable
First Name
Last Name
27
What city is your Family Doctor's clinic in?Skip if not applicable
28
For continuity of care, can we update your Family Doctor?* This field is required.When you consent below, we will notify your Family doctor if an assessment is booked and if not, the reason (if available and applicable). As part of notifying you Family Doctor, we will share your name, date of birth, the name of your psychologist, appointment date, and the Primary Concern(s) you reported at intake.
Yes
No
29
For continuity of care, can we update your Family Doctor? - SF Client Integration
Yes
No
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How did you hear about us?* This field is required.
Family or friend
Online search
Family Doctor
Pharmacist
Health/wellness professional
Other
31
Referral Channel - Salesforce Integration
Family or friend
Online search
Family Doctor
Pharmacist
Health/wellness professional
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Pharmacist or Health/Wellness Professional Name* This field is required.
First Name
Last Name
33
Home province acknowledgement (please read below)* This field is required.Our services are currently offered to individuals living in the following provinces: * Ontario * Alberta (currently doesn't assess Psychological concerns related to physical health) We are working to expand our reach to more provinces in the future!
I acknowledge I am currently located in the provinces listed above
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Fees and Cancellation Policy* This field is required.The full cost of the assessment is $1350. $375 is collected at the time of booking and the remaining $975 is collected after the clinical interview session. An assessment is a comprehensive exploration of your presenting concerns, not a guarantee of any specific diagnosis. We do not reimburse assessments where our clients do not get a specific (or any) diagnosis. Psychological services are not covered by government health Insurance plans (e.g. OHIP and AHS). However, you will be provided with a receipt for these services, which you can submit to your extended health insurance plan for possible reimbursement. Please contact your extended health insurer for details as some insurers will cover the full assessment but some may only cover direct hours and not admin portions. Whatever is not reimbursed may be claimed as a tax deduction under medical expenses. Please ask your accountant for details. Cancellation / rescheduling: 48 business hours of notice is required for cancellation or rescheduling in order to avoid the following fees: - If the clinical interview is cancelled or rescheduled with less than 48 business hours of notice, the $375 already paid will not be refunded and an additional $375 (on top of the $1350 assessment fee) will be charged to complete the assessment. - If the debrief session is cancelled or rescheduled with less than 48 business hours of notice, an additional $250 will be charged to complete the assessment. Extra fees: In the case that extra services are required, they will be billed at the rate of $250 / hour (prorated to the half hour). Examples include: - Additional interview or report-writing time is needed for cases where they are several diagnosis queries (e.g., ADHD, trauma, and mood disorders) -Additional time for file review if more than 5 pages of information (excluding report cards) is provided for the psychologist to review before or during the assessment (e.g., previous psychological or other medical reports) -Additional clinical interview time is required due to the client being late to the clinical interview or debrief meeting or in order to gain the necessary information to make an informed diagnosis. - Client questions after the debrief session that require a significant email or a follow-up call. - The client requests the psychologist to complete additional reports or forms. Extra psychometric testing (for testing there would be time charged for the psychologist to administer and interpret plus the cost of the testing) In any case where an additional fee would be imposed, your psychologist will notify you and confirm you agree to receiving the additional services and what the additional fees will be in advance of providing any additional services.
I understand and agree
35
Privacy of your information (Layla's Privacy Policy)* This field is required.We respect your right to privacy and follow all regulatory requirements for keeping your personal information private and secure. Limits to this confidentiality include any situation in which there are reasonable grounds for suspicion of harm to a child or serious imminent harm to yourself or others. In these situations, we have a right or obligation to break confidentiality for the safety of the person(s) at risk. For more information please review our complete Privacy Policy on www.layla.care/privacy-policy
I understand and agree
36
Is Client Eligible?
Yes
No
37
Based on the information provided, we can proceed to schedule your Psychological Assessment. If you are not ready, you can book a free informational call with our Program Coordinator or ask a question to learn more* This field is required.
Book a Psychological Assessment
Book a free call with our Program Coordinator
Ask a question
38
Ask your question here* This field is required.Our team will provide a response within 24 business hours
39
Salesforce Client Workflow Tag
WF-2023-07-13
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ON booking page redirect calculation field
Huge
Large
Normal
Small
Ok
Ok
41
Client is teen - calculation field (deactivated - no longer used)
YESNO
42
Client is teen - calculation field
Yes
No
43
ON - ADHD - Physical Health - calculation fieldIf ADHD OR Psychological concerns related to physical health (e.g., worrying about having a serious illness, frequently focusing on physical symptoms, such as pain) is Selected from main areas of concerns question
Yes
44
Bipolar - calculation fieldIf Bipolar Disorder is Selected from main areas of concerns question
Yes
45
BPD - calculation fieldIf BPD is Selected from main areas of concerns question
Yes
46
OCD - calculation field
Yes
47
Trauma - calculation field
Yes
48
ADHD - calculation field
Yes
49
Physical Health - calculation field
Yes
50
ON Adult ADHD Booking Page Redirect - calculation field
Yes
51
ON Adult OCD, Bipolar, Trauma, Physical Health Booking Page Redirect - calculation field
Yes
52
Global Modality
Individual
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Status
Intake Form Complete
Intake Question Asked
Should be Empty: