• 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.

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  • General Information - Adult Form


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  • Referral Information

  • Current Concerns

  • Services/Interventions Sought Previously

  • Have you had any of the following forms of psychological treatment? If so, how long did it last?

  • Family Background

  • (Please circle: Birth, Adoptive, or Foster)

  • If applicable .

  • Foster/Adoptive Information:

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  • Pre-Natal Period

  • Number of the following your mother had?


  • Birth History (Please approximate if you are unsure)

  • Please check the following problems that may have occurred during labor:


  • Post-Delivery Period

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  • Length of stay in hospital

  • Developmental History

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  • Please list the approximate age at which you accomplished the following developmental milestones. If you feel the milestone is not appropriate yet for the age of your child, please write N/A. If unsure, please write DK

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  • Medical/Health History

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  • Surgeries:

  • Hospitalizations:

  • Major accidents or injuries: 

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  • Family Medical History

  • Have any of your family members had the following problems/disorders? Please specify the family member’s relationship to you and whether the relationship is on the maternal (m) or paternal (p) side. Example: aunt (p) = aunt on the father’s side.

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  • Personal/Social Information

  • Educational History

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  • (Please attach a copy of the school evaluation if you have it)


  • Behavior

  • Were you ever

  • Do you currently (within the past 6 months) display any of the following behaviors frequently?


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  • Should be Empty: