Child/Adolescent Intake Form

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CReATE Child/Adolescent Intake Form

Please tell us a little more about your child so we can better understand your needs for testing. If you have difficulties with this form, please call our office at 828-231-3297

This form will take you approximately 20 - 30 minutes to complete, and is comprised mainly of checklists, allowing you to scan and complete quickly.

The information submitted in this form is guaranteed to be kept confidential and secure. Please wait for the confirmation page to appear once you submit your form.

If you need to save your information and come back later, you can select the "save" button at the bottom of the slide. An email will be sent to the email address you entered.
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General Child Information* This field is required.
Child's Name (First & Last)
Preferred Name
Child's Date of Birth
Please Select
Please Select
Male
Female
Other
Biological Sex/Gender
Current Grade
Please Select
Please Select
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child's Age
Current School
Please Select
Please Select
English
Spanish
Russian
Chinese
French
Arabic
Other
Primary Language
3
Please tell us about your child's biological sex and preferred gender :
4
Contact Information* This field is required.
Name of person completing this form
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Grandparent
Guardian
Non-Biological Parent
Other
Relation to child/adolescent
Email address
Please Select
Please Select
Male
Female
Other
Gender
Address (Street, City, State, & Zip)
Please Select
Please Select
Yes
No
Legal Guardian
Phone number
Please Select
Please Select
Email
Phone
Preferred Method of Contact
5
Please explain your relationship to child
Huge
Large
Normal
Small
Ok
Ok
6
Primary Parent /Legal Guardian Please list name and contact information for Legal Guardian
Name
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Grandparent
Legal Guardian
Non-Biological Parent
Other
Relationship to child/adolescent
Address (Street, City, State, & Zip)
Please Select
Please Select
Male
Female
Other
Gender
Email address
Phone number
Occupation
Place of Employment
7
Primary Parent /Legal Guardian
Name
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Grandparent
Legal Guardian
Non-Biological Parent
Other
Relationship to child/adolescent
Occupation
Please Select
Please Select
Single
Married
Separated
Divorced
Divorced/Remarried
Widowed
Marital Status
Place of Employment
Please Select
Please Select
English
Spanish
Russian
Chinese
French
Arabic
Other
Primary Language
8
Child lives with :* This field is required.
Both Parents
Only One Parent
Two Separate Households
Single Parent
Foster/Legal Guardian
Other
9
Is there another parent outside of the home who is involved in the child's life, has visitation, or has parental rights to the child's medical record?* This field is required.
YESNO
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Second Parent Information
Name of Second Parent
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Grandparent
Legal Guardian
Other
Relation to child/adolescent
Please Select
Please Select
Male
Female
Other
Gender
Email address
Phone number
Please Select
Please Select
Yes
No
Include Parent in Communications
Occupation
Place of Employment
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Other Parent Information
Name of Other Parent
Please Select
Please Select
Male
Female
Other
Gender
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Grandparent
Legal Guardian
Other
Relation to child/adolescent
Email address (If known)
Phone number (If known)
Occupation (If known)
Place of Employment (If known)
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Second Parent/Legal Guardian Information
Name of Second Parent/Legal Guardian
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Parent's Partner
Grandparent
Other
Relation to child/adolescent
Email address
Please Select
Please Select
Male
Female
Other
Gender
Phone number
Address (Street, City, State, & Zip)
Occupation
Place of Employment
13
Is there a Step-parent in Household 1 (your household)?* This field is required.
YESNO
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Household 1, Step-parent Information
Name of Household 1, Step-Parent
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Parent's Partner
Grandparent
Other
Relation to child/adolescent
Email address
Please Select
Please Select
Male
Female
Other
Gender
Phone number
Please Select
Please Select
Yes
No
Include Parent in Communications
Occupation
Place of Employment
15
Is there a Step-parent in Household 2?* This field is required.
YESNO
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Household 2, Step-parent Information
Household 2, Step-parent
Please Select
Please Select
Biological Parent
Adoptive Parent
Step Parent
Foster Parent
Parent's Partner
Grandparent
Other
Relation to child/adolescent
Email address
Please Select
Please Select
Male
Female
Other
Gender
Phone number
Please Select
Please Select
Yes
No
Include Parent in Communications
Occupation
Place of Employment
17
Is the other parent aware that you are seeking an evaluation for your child?* This field is required.
YESNO
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Please explain (e.g. whereabouts unknown, other parent not involved in child's life, other parent does not have custodial rights, etc.)
Huge
Large
Normal
Small
Ok
Ok
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Siblings Please tell us about child's siblings, or skip if none.
Age
Gender
Relation
Does this sibling live in the home?
Sibling 1
Row 0, Column 0
Male
Female
Other
Row 0, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 0, Column 2
Yes
No
Part-time
Row 0, Column 3
Sibling 2
Row 1, Column 0
Male
Female
Other
Row 1, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 1, Column 2
Yes
No
Part-time
Row 1, Column 3
Sibling 3
Row 2, Column 0
Male
Female
Other
Row 2, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 2, Column 2
Yes
No
Part-time
Row 2, Column 3
Sibling 4
Row 3, Column 0
Male
Female
Other
Row 3, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 3, Column 2
Yes
No
Part-time
Row 3, Column 3
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Age
Row 0, Column 0
Gender
Male
Female
Other
Row 0, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 0, Column 2
Does this sibling live in the home?
Yes
No
Part-time
Row 0, Column 3
Age
Row 1, Column 0
Gender
Male
Female
Other
Row 1, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 1, Column 2
Does this sibling live in the home?
Yes
No
Part-time
Row 1, Column 3
Age
Row 2, Column 0
Gender
Male
Female
Other
Row 2, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 2, Column 2
Does this sibling live in the home?
Yes
No
Part-time
Row 2, Column 3
Age
Row 3, Column 0
Gender
Male
Female
Other
Row 3, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 3, Column 2
Does this sibling live in the home?
Yes
No
Part-time
Row 3, Column 3
1 of 4
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Siblings Please tell us about child's siblings, or skip if none.
Age
Gender
Relation
This sibling lives in :
Sibling 1
Row 0, Column 0
Male
Female
Other
Row 0, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 0, Column 2
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 0, Column 3
Sibling 2
Row 1, Column 0
Male
Female
Other
Row 1, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 1, Column 2
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 1, Column 3
Sibling 3
Row 2, Column 0
Male
Female
Other
Row 2, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 2, Column 2
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 2, Column 3
Sibling 4
Row 3, Column 0
Male
Female
Other
Row 3, Column 1
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 3, Column 2
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 3, Column 3
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Age
Row 0, Column 0
Gender
Male
Female
Other
Row 0, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 0, Column 2
This sibling lives in :
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 0, Column 3
Age
Row 1, Column 0
Gender
Male
Female
Other
Row 1, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 1, Column 2
This sibling lives in :
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 1, Column 3
Age
Row 2, Column 0
Gender
Male
Female
Other
Row 2, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 2, Column 2
This sibling lives in :
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 2, Column 3
Age
Row 3, Column 0
Gender
Male
Female
Other
Row 3, Column 1
Relation
Full Sibling
Half-Sibling
Step-Sibling
Relative
Other
Row 3, Column 2
This sibling lives in :
Both Households
In Household 1
In Household 2
Outside both Households
Part-time in Household 1
Part-time in Household 2
Other
Row 3, Column 3
1 of 4
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Besides those already listed, is there anyone else living in the home? Do not include siblings or parents.* This field is required.
YESNO
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Please list anyone else living at home Please do not list siblings or parent/guardians.
Age
Gender
Relation to child/adolescent
1
Row 0, Column 0
Male
Female
Other
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Male
Female
Other
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Male
Female
Other
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Male
Female
Other
Row 3, Column 1
Row 3, Column 2
1
2
3
4
Age
Row 0, Column 0
Gender
Male
Female
Other
Row 0, Column 1
Relation to child/adolescent
Row 0, Column 2
Age
Row 1, Column 0
Gender
Male
Female
Other
Row 1, Column 1
Relation to child/adolescent
Row 1, Column 2
Age
Row 2, Column 0
Gender
Male
Female
Other
Row 2, Column 1
Relation to child/adolescent
Row 2, Column 2
Age
Row 3, Column 0
Gender
Male
Female
Other
Row 3, Column 1
Relation to child/adolescent
Row 3, Column 2
1 of 4
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Is there any legal action underway with the family? (e.g. custody, adoption, termination of parental rights, civil suit, etc.) * This field is required.
YESNO
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Please explain the legal action that is currently underway. 
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Referral Information
Who referred you to CReATE or how did you hear about us?
Please Select
Please Select
Yes
No
Not Applicable
Do you want us to have contact with your referral source?
Referral source's contact information or N/A
Were you referred to a specific psychologist at CReATE?
If yes, please list the name of the psychologist
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Briefly describe the reason for referral, concerns, or a little about your child/adolescent's current difficulties:
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What would you like to learn from this evaluation?
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How long have these concerns/difficulties been present?
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Type of evaluation:* This field is required.Please check one or all that apply:
Comprehensive Psychoeducational Evaluation: A comprehensive psychoeducational evaluation is a comprehensive and thorough evaluation that includes assessment of underlying cognitive, processing, learning, attentional, and academic abilities to better understand a child’s strengths and challenges and answer questions regarding possible cognitive disabilities, ADHD, or learning disabilities. This is a comprehensive evaluation that is typically sufficient for learning or attentional difficulties in school.
Add on Neuropsychological Testing - A few neuropsychological tests are a part of our comprehensive psychoeducational evaluation but not an in-depth evaluation of all domains. Some complex presentations require neuropsych testing (e.g., fetal alcohol exposure, seizure disorder, etc.). Other times, parents and/or educators may want the most in depth understanding of the child’s skills and abilities that are linked to brain functioning. For example, this includes additional assessment in the areas of language, attention, executive functioning, learning and memory, visual spatial, and/or fine motor, depending on the needs of the child (Neuropsychological Evaluation)
Add on Psychological Testing – A broad or general assessment of socioemotional and behavioral domains is included in the psychoeducational or neuropsychological evaluation but not an in-depth evaluation of these domains. Add on Psychological testing if mental health, socioemotional, or behavioral health concerns are prominent (e.g., trauma/attachment, OCD, mood, anxiety, Autism spectrum, etc.) (Psychological Evaluation)
Not sure if we need to Add on Psychological or Neuropsychological Testing – Please Advise. We can make recommendations after reviewing the intake if you are unsure.
Developmental - Ages 5 and under only
Gifted or Early Admission to K
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Areas of concern :* This field is required.(check all that apply)
Dyslexia or reading concerns
Dyscalculia or math concerns
Dysgraphia or writing concerns
General learning/processing concerns
ADD/ADHD or attentional concerns
Autism Spectrum concerns
Language concerns (receptive, expressive)
Behavioral concerns
Social concerns
Emotional concerns
General developmental concerns
Trauma or stressors
None
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Areas of concern :* This field is required.(check all that apply)
Anxiety or Mood concerns
Traumatic Brain Injury (TBI) and Concussion effects
Brain tumor or cancer effects
Epilepsy/Seizure Disorder effects
Other Brain related concerns
Fetal Alcohol Effects
Mental health concerns (or psychiatric)
Substance abuse concerns
Obsessive-Compulsive concerns
Personality or clinical concerns
Thought or psychosis concerns
None
32
Attention* This field is required.(check all that apply)
Frequently misses details or makes careless errors
Difficulty following instructions
Easily distracted
Difficulty sustaining attention over time
Avoids tasks that require sustained attention
Difficulty listening when spoken to
Loses things often
Difficulty listening with distractions present
Forgetfulness
None
33
Activity Level* This field is required.(check all that apply)
Acts impulsively (without thinking)
Physically active or hyperactive
Slow or sluggish (hypoactive)
Daydreams or seems "spaced out"
Difficulty sitting still for long
Fidgety or restless
Interrupts others often
Talks too much
Blurts out answers in class
Has difficulty waiting his/her turn
Difficulty remaining quiet
None
34
Processing Speed * This field is required.(check all that apply)
Difficulty making decisions quickly
Difficulty following conversations
Difficulty remembering new information
Requires more time to complete tasks
Difficulty getting started on tasks
Difficulty completing tasks
Slow to take in information
Slow to respond
Overwhelmed by too much information
None
35
Executive Functioning * This field is required.(check all that apply)
Difficulty following multi-step directions
Difficulty switching from an activity to another
Inflexible thinking
Difficulty organizing thoughts / actions
Difficulty organizing belongings
Difficulty with time management
Difficulty prioritizing tasks
Difficulty planning ahead
Difficulty with problem-solving
None
36
Nonverbal / Visual-Spatial * This field is required.(check all that apply)
Difficulty with hands-on tasks
Difficulty with sequencing familiar tasks
Right / Left confusion
Difficulty copying information
Difficulty learning shapes or symbols
Difficulty recognizing mistakes
Difficulty understanding maps/graphs
None
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Memory * This field is required.(check all that apply)
Difficulty remembering to do things
Difficulty remembering names, dates, numbers
Forgets to do things "chores, homework, etc"
Forgets needed or important items
Forgets to turn things in
Forgets newly learned concepts / information
Frequently misplaces items
None
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Coordination / Motor Function * This field is required.(check all that apply)
Difficulty with handwriting
Walks on tip toes
Difficulty buttoning shirt or tying shoelaces
Difficulty with gross motor skills
Problems with coordination or balance
Awkward gait when running or walking
Clumsy / Poor awareness of body in space
Repetitive movements (e.g. of hands/arms)
None
39
Language * This field is required.(check all that apply)
Receptive (i.e. understanding what is said)
Expressive (i.e. using words to communicate)
Difficulty finding the right word
Only wants to talk about one or two things
Perseverates on certain subjects
Word substitution errors
Recites or echoes phrases
Difficulty deciphering the meanings of words
Literal interpretation of language
Difficulty with back and forth conversation
None
40
Speech * This field is required.(check all that apply)
Articulation difficulties
Unusual speech volume (too loud or soft)
Stuttering
Repetitive speech or sounds
Halting / irregular speech pattern
Unusual tone or prosody
Slow/plodding speech
Rapid or pressured speech
None
41
Behavior * This field is required.(check all that apply)
Makes poor decisions
Behaviorally Dysregulated
Becomes upset if routine is changed
Is inflexible / stubborn
Temper Tantrums
Defiant or oppositional
Physically Aggressive (toward others)
Destruction of Property
Suspensions or Expulsions in School
Running away / disappearing for long periods
Legal Problems
Compulsive behavior
Self-injurious behavior
None
42
Social Relationships * This field is required.(check all that apply)
Prefers to play with younger children
Prefers to play with older children
Has difficulty initiating social interactions
Socially isolated
Feels rejected by others
Loss of significant relationship
A lot of conflict in relationships
Socially anxious
Has intense and short-lived relationships
Difficulty maintaining relationships
Poor boundaries in relationships
None
43
Social Skills * This field is required.(check all that apply)
Does not read social cues well
Does not understand jokes, literal
Timing seems off when interacting with peers
Poor eye contact
Difficulty understanding perspective of others
Was bullied or teased when younger
Has only a few narrow interests
Gullible or naïve
Not invited back for playdates or bday parties
Prefers to play by self
Bullies or teases others
Does not enjoy cooperative, imaginative play
Socially awkward
None
44
Sensory* This field is required.(check all that apply)
Auditory (sensitive to loud or certain sounds)
Tactile (sensitive to textures such as clothing)
Visual (aversion to or fascination with lights)
Olfactory (heightened sense of smell)
Strong food preferences/aversions
High or low tolerance for pain
Easily overstimulated in general
None
45
Perceptual * This field is required.(check all that apply)
Visions or visual hallucinations
Hearing voices (auditory hallucinations)
Hearing unexplainable or strange sounds
Tingling in body (hands, arms, feet, legs, etc.)
Sudden laughing / crying
None
46
Sleeping * This field is required.(check all that apply)
Difficulty settling for sleep at night
Hypersomnia (sleeping more than usual)
Insomnia
Snoring or waking suddenly for air
Sleep walking or talking
Nighttime bed wetting
Recurrent nightmares
Night terrors
Decreased need for sleep
None
47
Eating * This field is required.(check all that apply)
Limited food choices
Recent weight gain
Unintended weight loss
Intended weight loss
Frequent headaches
Frequent stomachaches
Changes in Appetite
Abdominal Pain
Restrictive eating
Binging/Purging
None
48
Physical * This field is required.(check all that apply)
Breathing problems / wheezing
Dizziness or fainting
Enuresis (poor bladder control)
Encopresis (bowel control)
Frequent headaches
Constipation
Migraine headaches
Loose stools
Tics
Sexual Dysfunction or Problems
Chronic or Acute Pain
None
49
Mood * This field is required.(check all that apply)
Low self-esteem
Sadness or confusion about gender
Poor self-confidence
Has anxiety about tests / school
Easily angered / irritable
Feeling sad / blue / depressed
Has increased energy
Feeling anxious / stressed / worried
Suspiciousness / Paranoia
Fears separation from parents
Has decreased energy
Has specific phobias
Often emotionally dysregulated
Suicidal ideation
Feels guilty
Withdrawn
Easily startled
None
50
Trauma* This field is required.(check all that apply)
Physical abuse
Emotional abuse
Sexual abuse or sexual assault
Accident or injury
None
Other
51
Thoughts * This field is required.(check all that apply)
Racing Thoughts
Mental rituals
Unusual thoughts
Preoccupations
Disruptive thoughts, memories, or "flashbacks"
Obsessions (e.g. intrusive thoughts)
Thoughts of harming self
Compulsions (e.g. mental rituals)
Thoughts of harming others
Phobias
Violent fantasies
Recurrent thoughts of death
Fears of hurting others
None
52
Adaptive behavior * This field is required.(check all that apply)
Difficulty getting self dressed
Difficulty completing daily tasks independently
Difficulty with toileting
Difficulty with feeding
Difficulty maintaining clean hygiene
Difficulty with nighttime or morning routine
None
53
Description for any items checked (Optional):
54
Were any of these concerns/difficulties the result of a known event/injury (e.g., brain injury, seizure, illness etc.)?* This field is required.
Yes
No
55
If Known Event, please check all that apply:
Brain Injury (TBI)
Stroke
Brain Aneurysm
Seizures
Brain or Spinal Tumor
Trauma/Stressor/Transition
Concussion with loss of consciousness
Substance Use/Overdose
Concussion without loss of consciousness
Psychiatric event (e.g. hospitalization)
Major Illness (cancer, lupus, MS, etc.)
Other
56
Symptoms that followed Known Event(check all that apply)
Falling / stumbling
Weakness in hands, arms, feet, legs, eyes, etc.
Slowness of movements
Hand tremor
Chronic fatigue
Loss of strength
Muscle cramps
Loss of coordination
Dizziness
None
57
Symptoms that followed Known Event(check all that apply)
Slurring of speech
Change in quality of voice
Hearing ringing or buzzing noises
Change of smell/unexplained bad odors
Loss of taste or change of sense of taste
Blurring, blindness or double vision
Loss of sense of smell
Facial numbness, pain or drooping
Involuntary or repetitive movements
None
58
Which of the following scans/tests have previously been performed?(check all that apply)
CT scan
Metabolic Panel (e.g., blood work)
MRI
Chest X-Ray
EEG
PET Scan
Urinalysis
MEG Scan
None
59
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60
Reading* This field is required.(check all that apply or none)
Difficulty learning to identify letter sounds
Difficulty learning to identify letters by symbol
Reverses letters
Difficulty mastering sight words
Difficulty sounding out or decoding words
Difficulty learning to blend sounds
Poor tracking
Frequent word reading errors
Difficulty reading fluently or smoothly
Poor comprehension
Resists reading
More difficulty learning to read than expected
Reads slowly
Reading seems lower than verbal/oral abilities
Tires easily when reading
None
61
Reading - (During middle school and/or high school years)(check all that apply)
Difficulty completing longer reading passages
Difficulty comprehending longer passages
Recall of reading passages is poor
Does not grasp main ideas or key concepts
Overhwhelmed by the volume of reading
None
62
Math* This field is required.(check all that apply or none)
Poor arithmetic calculation
Poor understanding of math concepts
Difficulty mastering basic math facts
Tires easily when working math
Difficulty recalling previously learned concepts
Difficulty recalling learned strategies
Difficulty learning to count
Poor number sense
Difficulty learning math facts
None
63
Math - (During middle school and/or high school years)
Difficulty understanding more complex math
Does not show his/her work
Difficulty with geometry or spatial math
Recall of learned math concepts is poor
None
64
Writing* This field is required.(Check all tha apply or none)
Difficulty with early handwriting
Letter reversals
Continued poor handwriting
Poor spelling
Difficulty getting thoughts on paper
Writing is laborious, arduous
Difficulty organizing sentences/paragraphs
Poor use of grammar in writing
Resists writing
Writing below expectation of verbal abilities
Poor punctuation, capitalization
Does not complete writing assignments
None
65
Writing - (During middle school and/or high school years)
Difficulty getting started on essays or papers
Difficulty completing essays or papers
Does not know how to keyboard efficiently
Difficulty adding detail or expanding on theme
Difficulty organizing thoughts in writing
Difficulty communicating through writing
None
66
Previous schools attended
Name of School/Preschool or Childcare
City
Grades
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Name of School/Preschool or Childcare
Row 0, Column 0
City
Row 0, Column 1
Grades
Row 0, Column 2
Name of School/Preschool or Childcare
Row 1, Column 0
City
Row 1, Column 1
Grades
Row 1, Column 2
Name of School/Preschool or Childcare
Row 2, Column 0
City
Row 2, Column 1
Grades
Row 2, Column 2
Name of School/Preschool or Childcare
Row 3, Column 0
City
Row 3, Column 1
Grades
Row 3, Column 2
Name of School/Preschool or Childcare
Row 4, Column 0
City
Row 4, Column 1
Grades
Row 4, Column 2
1 of 5
67
Educational Placement and Prior Services* This field is required.(check all that apply)
Public School
Private School
Regular class
504 Plan
Special Education (IEP)
Tutoring
Home school
Speech-Language Therapy
Occupational Therapy
None
68
Prior Testing* This field is required.(check all that apply)
School-based testing
Neuropsychological Evaluation
Psychoeducational Evaluation
Psychological Evaluation
Speech-Language Evaluation
OT Evaluation
QEEG/SPECT
None
69
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70
Prior Diagnoses * This field is required.(Previously diagnosed elsewhere)
ADHD or "ADD"
Learning Disorder or disabilty
Autism Spectrum Disorder or Asperger’s
Intellectual Disability
None
71
Pregnancy Information* This field is required.(check all that apply)
Pre-eclampsia/Toxemia
Hypertension/High Blood Pressure
Gestational Diabetes
Blood (RH) Incompatibility
Injury/Accident
Illness/Fever
Anemia (low iron)
Emotional strain/Trauma
Fertility Treatment
Postpartum Depression
None
Other
72
To the best of your knowledge, did the biological mother smoke, drink alcohol, or use drugs while pregnant with this child?* This field is required.
No
Yes
Don't Know
Suspected
73
Birth History * This field is required.(check all that apply and enter Birth Weight)
Domestic adoption
Foreign adoption
Full-term (38-42 weeks gestational age "GA")
Mild Prematurity (3 weeks early, 37 GA)
Moderate preterm (4-7 weeks early, 33-36 GA)
Very preterm (8-12 weeks early, 28-32 GA)
Extremely preterm (12+ weeks premature)
Late-term (42+ weeks GA)
C-section
Breech position
Forceps
Cord around neck
Other
74
Neonatal History* This field is required.(check all that apply)
Breathing problems
Meconium staining
Low Apgar Score (< 7)
Lacking oxygen
Multiple births
Jaundice
Birth defects noted
Admitted to NICU
Drug withdrawal
Sent home on apnea monitor (CPAP)
Excessive crying/colic
Failure to thrive
Hospitalization
Seizures/convulsions
None
Other
75
Early Development: Communication * This field is required.(check all that apply)
Delayed language development
Did not respond to name by 1 year of age
Did not wave "bye-bye" by 1 year of age
Delayed in pointing for communication
Did not use gestures to communicate
Did not enjoy peek-a-boo or baby games
Regressed in language skills
Had repetitive language or echolalia
None
76
Early Development: Physical* This field is required.(check all that apply)
Delayed gross motor development
Delayed fine motor development
Poor balance or coordination
Flapping hands or movements, rocking
Difficulty learning to tie shoes
Resisted physical activity
Low Muscle Tone
Concerns about head size
Difficulty with riding toys
None
77
Early Development* This field is required.(check all that apply)
Delayed in learning to feed or dress self
Delayed in potty training
Lined up toys or played with parts of toys
Did not enjoy cooperative/imaginative play
Problems with attachment
Did not share facial expressions
Learning problems in preschool
Resisted coloring/drawing in preschool
Social problems in preschool
Behavior problems in preschool
Very active or hyperactive
Problems with biting in preschool
Asked to leave preschool
None
78
Early Intervention and Assessment* This field is required.(check all that apply)
Early Intervention (CDSA)
Speech-Language Therapy
Occupational Therapy
Physical Therapy
Preschool EC services
Speech-Language Evaluation
OT Evaluation
None
79
Description of any problems listed above (optional)
80
Medical Information
Name of Pediatrician or PCP and Practice
Approximate Date of Last Visit
Please Select
Please Select
Yes
No
Were vision and hearing screenings normal?
If no, please explain
Please Select
Please Select
Yes
No
Are your child's immunizations up to date?
If no, please explain
81
Ear, Nose, & Throat* This field is required.
Chronic Ear Infections
Tubes in ears
Strep Throat
Tonsils or adenoids removed
Swallowing Disorder
Asthma
Seasonal Allergies
Dizziness (e.g., vertigo, BPPV)
None
Other
82
Cardiovascular & Endocrine* This field is required.
Heart difficulties or surgeries
High or Abnormal Blood Pressure
High Cholesterol
Heart Disease
Diabetes Type I
Diabetes Type II
Hypoglycemia
None
83
Genital-Urinary & Gastrointestinal* This field is required.
Enuresis or encopresis
Colon Disease (e.g., Chron’s, IBS)
Regular Urinary Tract Infections
Gastroesophageal Reflux Disease (GERD)
Pancreatitis
Liver Disease (e.g., hepatitis)
None
84
Muscular-Skeletal* This field is required.
Cerebral Palsy
Broken bones
Physical Abnormality
Amputation
Fibromyalgia
Chronic Fatigue Syndrome
None
85
Oncology/Hematology* This field is required.
Brain Tumor
Leukemia
Lymphoma
Sickle cell anemia
Hemophilia
Myeloma
None
86
Genetic or Acquired* This field is required.
Fragile X
Down Syndrome
Mitochondrial Disease
Lead poisoning
Toxic exposure
Physical injuries
None
87
Infectious Disease * This field is required.
Meningitis
Encephalitis
HIV
Tuberculosis
COVID-19 Infection
None
88
Description of any of the items above (Optional):
89
Is your child prescribed or taking any medications or alternative medicines or supplements?* This field is required.
Yes
No
90
Medication/Supplements
Name of Medication/Supplement
Past Use
Current Use
Dosage/Frequency
Purpose
1
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2
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3
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4
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Name of Medication/Supplement
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Current Use
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Dosage/Frequency
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Purpose
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Name of Medication/Supplement
Row 1, Column 0
Past Use
Row 1, Column 1
Current Use
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Dosage/Frequency
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Purpose
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Name of Medication/Supplement
Row 2, Column 0
Past Use
Row 2, Column 1
Current Use
Row 2, Column 2
Dosage/Frequency
Row 2, Column 3
Purpose
Row 2, Column 4
Name of Medication/Supplement
Row 3, Column 0
Past Use
Row 3, Column 1
Current Use
Row 3, Column 2
Dosage/Frequency
Row 3, Column 3
Purpose
Row 3, Column 4
Name of Medication/Supplement
Row 4, Column 0
Past Use
Row 4, Column 1
Current Use
Row 4, Column 2
Dosage/Frequency
Row 4, Column 3
Purpose
Row 4, Column 4
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91
Mental Health (previously diagnosed)* This field is required.
Anxiety Disorder
Depressive Disorder
Bipolar Disorder
Psychotic Disorder (e.g. Schizophrenia)
PTSD
Substance Use Disorder
Eating Disorder
Obsessive Compulsive Disorder
Phobias
Personality Disorder
Conduct Disorder or Behavioral Disorder
Substance Use Disorder
None
92
Treatment History* This field is required.(check all that apply)
Outpatient therapy
Psychiatric Monitoring/Treatment
Psychiatric Hospitalization
Psychopharmacological Treatment
Partial Hospitalization
Intensive Outpatient Program (IOP)
Residential Treatment
Substance Use Treatment
Wilderness Therapy
Neurofeedback
None
Other
93
Does the client have a history of substance use?* This field is required.
YESNO
94
Substance Use
No Use
Only Rarely
Current Use
Past Use
Frequency
Date of Last Use
Unknown
Alcohol
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Marijuana
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Cocaine
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Heroin
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
MDMA (e.g. Ecstasy)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Hallucinogenics (e.g. LSD, "Acid")
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Prescription Pain (Opiates)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Prescription Anxiolytic (Valium, Xanax, etc.)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
Other
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Alcohol
Marijuana
Cocaine
Heroin
MDMA (e.g. Ecstasy)
Hallucinogenics (e.g. LSD, "Acid")
Prescription Pain (Opiates)
Prescription Anxiolytic (Valium, Xanax, etc.)
Other
No Use
Row 0, Column 0
Only Rarely
Row 0, Column 1
Current Use
Row 0, Column 2
Past Use
Row 0, Column 3
Frequency
Row 0, Column 4
Date of Last Use
Row 0, Column 5
Unknown
Row 0, Column 6
No Use
Row 1, Column 0
Only Rarely
Row 1, Column 1
Current Use
Row 1, Column 2
Past Use
Row 1, Column 3
Frequency
Row 1, Column 4
Date of Last Use
Row 1, Column 5
Unknown
Row 1, Column 6
No Use
Row 2, Column 0
Only Rarely
Row 2, Column 1
Current Use
Row 2, Column 2
Past Use
Row 2, Column 3
Frequency
Row 2, Column 4
Date of Last Use
Row 2, Column 5
Unknown
Row 2, Column 6
No Use
Row 3, Column 0
Only Rarely
Row 3, Column 1
Current Use
Row 3, Column 2
Past Use
Row 3, Column 3
Frequency
Row 3, Column 4
Date of Last Use
Row 3, Column 5
Unknown
Row 3, Column 6
No Use
Row 4, Column 0
Only Rarely
Row 4, Column 1
Current Use
Row 4, Column 2
Past Use
Row 4, Column 3
Frequency
Row 4, Column 4
Date of Last Use
Row 4, Column 5
Unknown
Row 4, Column 6
No Use
Row 5, Column 0
Only Rarely
Row 5, Column 1
Current Use
Row 5, Column 2
Past Use
Row 5, Column 3
Frequency
Row 5, Column 4
Date of Last Use
Row 5, Column 5
Unknown
Row 5, Column 6
No Use
Row 6, Column 0
Only Rarely
Row 6, Column 1
Current Use
Row 6, Column 2
Past Use
Row 6, Column 3
Frequency
Row 6, Column 4
Date of Last Use
Row 6, Column 5
Unknown
Row 6, Column 6
No Use
Row 7, Column 0
Only Rarely
Row 7, Column 1
Current Use
Row 7, Column 2
Past Use
Row 7, Column 3
Frequency
Row 7, Column 4
Date of Last Use
Row 7, Column 5
Unknown
Row 7, Column 6
No Use
Row 8, Column 0
Only Rarely
Row 8, Column 1
Current Use
Row 8, Column 2
Past Use
Row 8, Column 3
Frequency
Row 8, Column 4
Date of Last Use
Row 8, Column 5
Unknown
Row 8, Column 6
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95
Substance use has contributed to(check all that apply)
Feeling guilty or ashamed
Inability to live independently
Criticism from significant others
Failing or performing poorly in school
Loss of significant relationships
Loss of job or difficulty holding down a job
None
Other
96
Please list names of any current treatment providers or others involved in your child's care (therapist, psychiatrist, developmental pediatrician, etc.)
97
Family History of the following:* This field is required.Neurodevelopmental
ADHD or "ADD"
Dyslexia or Reading LD
Dysgraphia or Writing LD
Dyscalculia or Math LD
Language Disorder
Autism Spectrum Disorder or Asperger’s
Intellectual Disability
Learning difficulties of unknown origin
None
98
Family History of the following: * This field is required.Mental Health
Anxiety Disorder
Depressive Disorder
Bipolar Disorder
Psychotic Disorder (e.g., Schizophrenia)
Substance Use Disorder
Eating Disorder
Obsessive Compulsive Disorder
Phobias
Personality Disorder
Conduct Disorder or Behavioral Disorder
None
99
For any Family History items checked, please list the family member's relation to the child (e.g., parent, sibling, cousin, etc.)
100
Psychosocial or Family Stressors:* This field is required.(check all that apply)
Family financial stressors
Difficult move
Change in schools
Other difficult transition
Marital discord / conflict
Recent or impending divorce
Sibling discord / conflict
Child separated from one or both parents
Residential instability
Asked to leave school
Neglect or inadequate care
Parental legal problems
Parental rights terminated
Recent loss of loved one
Recent loss of significant relationship or friendship
None
Other
101
Please list child's strengths (hobbies, interests, achievements, positive traits, etc.)
Strengths and Positive Traits:
Hobbies and Interests:
Extracurricular Activities:
Academic or Nonacademic Achievements:
102
Thank you for completing this form. The information submitted is guaranteed to be kept confidential and secure. We will be in touch regarding options for testing, pricing, and scheduling soon. Please be patient as we review each intake form to make the best recomendations for your child.
103
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