Pre-Bariatric Surgery Mental Health Evaluation

1. Complete Patient Registration
2. Complete the Assessment and Interview Evaluation
3. Pay $150 with a Debit or Credit Card
PLEASE COMPLETE ALL SECTIONS IN ONE SITTING. UPON COMPLETION CLICK THE "SUBMIT" BUTTON..

Although some patients may finish sooner, we recommend allowing at least 20-40 minutes to complete. Please follow the directions at the top of the page in each section.
We respect your privacy and will never disclose your personal information without your written consent.

Don’t accept any help in answering questions. The answers must be solely your own.
If you have any questions please call us at (806) 239-3848.
First Name*
Middle Name
Last Name*
Gender
Address
Street Address City State ZIP Code
Best Number To Reach You At
Phone Number*
Age
Marital Status
Employment
Employer if Applicable
Occupation if Applicable
Date of Birth
MM/DD/YYYY
Email Address
Clinic/Surgeon
Height
Feet
Inches
Weight
lbs
Approximate Month and Day of Surgery
MM/DD
Are you currently or in the past, have you seen a mental health therapist?
Is this your first bariatric mental health evaluation?
Check To Agree*
- I agree to online inventories and further agree to telephone/FaceTime interviews.

Wahler Physical Symptoms Inventory