Registration - History Form (22 and older)

Please fill out this form to the best of your knowledge. If some questions are not applicable to you, write N/A. If you need more space or wish to make additional comments, please write on the back or attach a separate sheet.
Form completed by:
Relationship if not client:
Date form completed:

Month Day Year
Date
General Information - Adult Form
Full Name
First Middle Last
Handedness:

Right Left
Date of Birth:

Month Day Year
Date
Age:
Ethnic/Cultural Background:
Primary language spoken in the home:
Other language spoken in the home:
Referral Information
Who referred you?
Reason for Referral:
Who is your primary care doctor?
Phone:
If you involved in litigation, who is your attorney?
**If you DO NOT want us to send a copy of our report to the referral source

please mark here
Current Concerns
What is the main reason for your visit today?
How long have you had these problems?
What are you hoping to achieve at the completion of this evaluation?

Family Background
(Please circle: Birth, Adoptive, or Foster)
Birth / Adoptive / Foster Mother's Name:
Age
Education (Yrs)
Occupation:
Birth / Adoptive / Foster Father's Name:
Age
Education (Yrs.)
Occupation:
Stepmother's Name:
Age
Education (Yrs.)
Occupation:
Stepfather's Name:
Age
Education (Yrs.)
Occupation:
If applicable .
Legal Guardian's Name:
Age
Education (Yrs.)
Address (if different from yours)
Occupation:
Employer
Work Phone:
Home Phone:
Relationship to you:
Foster/Adoptive Information:
When were you first placed in foster care?
Why were your placed in foster care?
Were you adopted?

Yes No
If yes, specify country of origin if international
Age when your were first in home:
Date of legal adoption:

Month Day Year
Date
When did you know you were adopted?
How many different foster care / adoptive placements did you experience?
What type of placements did you experience (e.g., orphanage, foster home, group home, shelter care, kinship home, hospitalization, etc.)?
Do you have any contact with biological parents?

Yes No
If yes, with whom, how often, how did it feel?

LIST ALL PEOPLE WITH WHOM YOU CURRENTLY RESIDE:

Name of Household Members

Age

Gender

Relationship to You

Highest Grade Completed

If any brothers or sisters are living outside the home, list their names, ages, where they are living, and their occupation:
Are you separated or divorced:

Yes No
When did you separate/divorce?
Who has physical custody of any children?
Who has legal custody of the children?
How often does the other parent see these children?
Have there been any major changes within the family life or your living situation that have affected you (e.g., deaths, moves, divorces, loss of job, etc.)?

⁭ No ⁭ Yes (describe below)

List any major life events in chart below

Event

Date

Your Age

If you are still in school please list your courses and ratings

Excellent

Above Average

Average

Somewhat of a problem

Problematic

Course 1

Course 2

Course 3

Course 4

Course 5

Course 6

Course 7

Course 8

Course 9

General Information - Adult Form