Forms

For Dr. Locke’s New or Continuing Patients

As we have agreed to work together, there are a number of routine forms I will need you to fill out and/or read. For your convenience, we have combined these routine new-patient forms into a single PDF, the “New-Patient Forms Package” that appears below.* From time to time, various other specific forms, also below, may be helpful in our assessment. I look forward to working with you.

For Other Situations (those who are not currently patients)

I am pleased to be able to make available to you these questionnaires and forms that may help you to describe your symptoms to your current clinician (primary care doctor or behavioral health specialist). However, it’s important to understand that by making these forms available to you so that you can track your symptoms, they are not intended to be construed as beginning a formal doctor-patient relationship. They should only be used to provide structured information for another doctor who is already engaged in a doctor-patient relationship with you. 

*If at any stage you want to download individual components of that New-Patient Package, you can find the individual components here.

SCHEDULE A Consultation

NEW PATIENT FORMS PACKAGE

A PDF that includes the several routine forms necessary for new patients.

download

HEALTH INFO
RELEASE

Release of Medical Information Form

download

PSYCHIATRIC SYMPTOM CHECKLIST

Psychiatric Symptom Checklist (PHQ9 and GAD7)

download

MEDICAL SYMPTOM CHECKLIST

Medical Symptom Checklist 

download

OCD CHECKLIST

OCD Checklist 

download

HPPD
QUESTIONNAIRE

Questionnaire to Assess Persistent Visual Symptoms After Hallucinogen Use

download

DRUG ABUSE SCREENING TEST

Drug Abuse Screening Test

download

Rating Scale for Attention Deficit Hyperactivity Disorder

Wender Utah Rating Scale for Attention Deficit Hyperactivity Disorder

download

 

ADHD Severity Rating Scale (ASRS)

Adult ADHD Self-Reporting Scale (ASRS-V1.1) Symptom Checklist

download

ABNORMAL INVOLUNTARY MOVEMENTS

Abnormal Involuntary Movements Screener

download

Mood Disorder

The Mood Disorder Questionnaire

download

Panic and Phobia

The Panic and Phobia Questionnaire

download

Out-of-Network PA

Out of Network PA

download

Loneliness Scale

Loneliness Scale: A Self-Assessment Tool

download

PQ-16

PQ-16: Psychosis Screening Tool

download

VSS Questionaire

Visual Snow Syndrome Questionaire

download