Name: Sincere Psychiatry
Address: 16244 S Military Trail, Unit 130, Delray, FL33484
Telephone: +1-(561) 455-2603
Price range: $$

We love to hear from our clients, please let us know if there are any areas that you think we could improve upon.

Name
This field is for validation purposes and should be left unchanged.
Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.
0 Never

1 Rarely

2 Sometimes

3 Often

4 Very often

QUESTIONS

RATING SCALE
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
Never Rarely Sometimes Often Very Often
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
Never Rarely Sometimes Often Very Often
3. How often do you have problems remembering appointments or obligations?
Never Rarely Sometimes Often Very Often
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
Never Rarely Sometimes Often Very Often
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
Never Rarely Sometimes Often Very Often
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
Never Rarely Sometimes Often Very Often
Name*
Email*
Phone*
Today's Date*
MM slash DD slash YYYY
SMS Opt-in or Opt-out
- Opt into receiving SMS
- Opt out of receiving SMS
By providing my phone number, I consent to receive SMS text messages for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. Privacy Policy | Terms and Conditions

Now accepting new patients

Same-day appointments available

Visit Us

Our goal is for you to leave our office with a memorable and enjoyable experience, which is why our welcoming and compassionate staff will do everything they can to make you feel right at home.

Call Us Text Us

What Can We Improve

Visit Us

Accessibility Tools