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)

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

Was testing been completed by school?

Yes No
Date:

Month Day Year
Date
(Please attach a copy of the school evaluation if you have it)
Present class placement:

Regular class Bilingual/ESL Gifted & Talented

People tell me that I (or I noticed that) ....

Not at all

Just a little

Pretty much

Very much

N/A

Talk too much

Blurt out comments, interrupt, or am opinionated.

Seem to miss the point of jokes or follow other peoples’ stories.

Don’t read as much as I use to.

Ask for help when I can do something myself or try to do things myself
when I’ve been told not to.

Argue more than I used to

Have trouble keeping track of my medications.

Have more fender benders or other people don’t seem as comfortable being in the car with me.

Blame others for his or her mistakes or misbehaviors

Am touchy or easily annoyed by others

Is angry and resentful

Drink more than I used to

Threaten or intimidate others.

Watch more TV than I used to.

Lie to get out of trouble or to avoid obligations

Overdraw my checking account or go over the limit on my credit cards

Avoid certain places or people

Have nightmares

People tell me that I (or I noticed that) ....

Not at all

Just a little

Pretty much

Very much

N/A

Have used a weapon that can cause physical harm (bat, knife, brick, gun)

Have wondered if it might be better if I were dead

Feel flat, empty or disconnected from others

Can’t tolerate noise or crowds the way I used to.

Find most things to be too much work to bother with

Worry about things more than I used to

Am in pain much of the time

Have decreased interest or pleasure in daily activities

Have significant weight loss or gain, poor appetite or over-eating without
deciding to diet or trying to gain.

Have difficulty sleeping or is sleeping too much

Startle easily or jumpier than I used to be.

Seems excessively agitated___or slowed down___ (check if positive)

Feels lonely, unwanted, or unloved; complains that “no one loves him or
her”

Have difficulty making decisions.

Have feelings of hopelessness

Have talked about or attempted suicide

Feel that worry is difficult to control

Am restless or feels keyed up or “on edge”

Have headaches or stomachaches.

Am irritable or grouchy

Has muscle tension

Have repetitive behaviors, such as hand-washing, lining things up, checking
on things before leaving a room or leaving the house, or mental acts such as a need to keep counting things or repeating words over and over.

Have thoughts that persist and keep coming back, that cause worry or
anxiety

Smell or see things that others do not.

Should be Empty:

General Information - Adult Form

Referral Information

Current Concerns

Services/Interventions Sought Previously

Family Background

Foster/Adoptive Information:

Pre-Natal Period

Birth History (Please approximate if you are unsure)

Post-Delivery Period

Developmental History

Medical/Health History

Family Medical History

Personal/Social Information

Educational History

Behavior