Intake Questionnaire for Adult Evaluation Clients

Intake Questionnaire for Adult Evaluation Clients

THE FAMILY GUIDANCE AND THERAPY CENTER IN PETALUMA
This questionnaire is designed for the purpose of getting to know you better in order to provide the best possible evaluation. Please complete this form honestly and completely as possible. All information that you provide us will be kept confidential as requires by state and federal law.
Client Information
Date

MonthDayYear
Date
Social Security Number
Legal Name
Legal Middle Name
Legal Last Name
Name You Go By

First NameLast Name
Pronouns

She/herHe/himThey/themOther
Suffix

Jr.Sr.IIIIV
Age
Date of Birth
Marital Status:

SingleSingle remarriedMarried or engagedSeparated widowedDivorced cohabitating
Sexual Orientation (optional):

HeterosexualHomosexualBisexualAsexualOther
Gender Identity (optional):

MaleFemaleNon-BinaryOther
Race:

African American or BlackAmerican Indian/Alaskan NativeAsianOther Pacific IslanderLatino(a)Native HawaiianWhiteOther
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Education
Client Education (check highest level completed):

Graduate/Professional DegreeBA, BS, or 4-year DegreeAssociates DegreeTechnical School DegreeHigh School GraduateGED Diploma1-3 years of High SchoolCompleted up to Ninth GradeCompleted less than Ninth Grade
Did you receive special assistance in school?

YesNo
Please explain
Are you currently attending school?

YesNo
What is the name of your school?
Did you have any disciplinary problems in school?

YesNo
Please explain
EMPLOYMENT

Current Employment:


Occupation
Place of Employment
Employer’s Name
Date of Hire

Employment History (most recent first)

	Occupation	Dates	Reason for Leaving
Job #1
Job #2
Job #3
Job #4

Have you served in the military?

YesNo
Please briefly describe:
What type of discharge (separation) did you receive?
INSURANCE INFORMATION
Name of Insurance Company:
Group Number:
Policy Holder Name:
Policy Holder Birthdate:

MonthDayYear
Policy Number + Suffix:
Primary Care Provider Name:
Insurance Claims Address:
Customer Service Phone Number:
Effective Date of Policy:

MonthDayYear
REFERAL INFORMATION
In your own words, describe the current problems you are experiencing as you see them:
How long has this been going on?
What prompted you to seek an evaluation at this time?
What do you hope to gain from this evaluation?
Have you had any previous evaluations? What were the results?
Describe any concerns or information you think will be helpful for this evaluation:
FAMILY HISTORY
Parent 1

BiologicalStepAdoptive father/mother
Age
Occupation:
Frequency of contact:
Is this parent deceased?

YesNo
Please indicate cause of death:
What was your age at the time of death?
Parent 2

BiologicalStepAdoptive father/mother
Age
Occupation:
Frequency of contact:
Is this parent deceased?

YesNo
Please indicate cause of death:
What was your age at the time of death?
Parent 3

BiologicalStepAdoptive father/mother
Age:
Occupation:
Frequency of contact:
Is this parent deceased?

YesNo
Please indicate cause of death:
What was your age at the time of death?
Additional Parent

BiologicalStepAdoptive father/mother
Age:
Occupation:
Frequency of contact:
Is this parent deceased?

YesNo
Please indicate cause of death:
What was your age at the time of death?
Siblings
Sibling 1

BiologicalStepAdoptive
Sibling 2

BiologicalStepAdoptive
Sibling 3

BiologicalStepAdoptive
Sibling 4

BiologicalStepAdoptive

	Name	Gender	Age	Are you close to them?
Sibling 1
Sibling 2
Sibling 3
Sibling 4

During your childhood, did you live any significant period of time with anyone other than your parents?

YesNo
Please give the person’s name and relationship to you:
Name:
Relationship to you:
If any of your biological relatives have had any of the following conditions, please write the person’s relationship to you (i.e. aunt, uncle, grandmother, grandfather, brother, sister) next to the condition.

	Family Member / Relative:
Autism Spectrum Disorder, Asperger Syndrome, (PDD NOS)
Communication Disorder
Convulsions, Seizures, Epilepsy
Cerebral Palsy, Muscular Weakness
Hearing Loss
Intellectual Disability
School Difficulties
Severe Visual Impairment
Developmental Delay, Speech Delay
Reading Difficulty
Anxiety Disorder
Psychosis
Attention Deficit Hyperactivity Disorder (ADHD)
Depression
Bipolar Disorder
Mood Disorder
Alcoholism/Substance Abuse or Dependency
Autoimmune Disorders (e.g. thyroid, MS, lupus)
Other

Please specify type of autoimmune disorder:
Please specify the 'other' diagnosis:
MEDICAL HISTORY
Are you currently under treatment for any medical condition?

YesNo
Please describe
Have you ever experienced abuse?

YesNo
Please indicate:

VerbalEmotionalPhysicalSexualNeglect
Please describe
Are you currently taking psychiatric medication?

YesNo

Have you taken psychiatric medication in the past?

YesNo

Are you currently taking non-psychiatric medication?

YesNo

List any prior illnesses, operations and/or accidents:
Have you ever received an evaluation for ASD, Asperger Syndrome, or PDD-NOS?

YesNo

Comments:
Have you ever received any developmental, cognitive, achievement or IQ Testing?

YesNo

Comments:
Have you ever received any behavioral or mental health evaluations? (for concerns such as ADHD, depression, anxiety, psychosis, conduct, etc.)

YesNo

Comments:
Have you ever received any other type of evaluation for other disabilities or concerns? (such as OT, Speech, medical evaluations)

YesNo

Comments:
Please check any symptoms you have experienced in the past month:

Sadness / DepressionAnxiety / WorryWeight loss / gainSleep DisturbancePanic AttacksThoughts about Harming or Killing YourselfDifficulty with CommunicationDifficulty with Social RelationshipsRituals or Repetitive BehaviorUnusual Visual ExperiencesHearing Voices when no one else is presentHigh levels of AngerDifficulty ConcentratingHigh levels of StressFear of certain Objects or Situations
Should be Empty:

	Name of Medication	Dosage	How long have you been taking it?	Has it been helpful?
Medication #1
Medication #2
Medication #3
Medication #4

	Name of Medication	Dosage	First/Last time you took it	Effect of medication
Medication #1
Medication #2
Medication #3
Medication #4

	Name of Medication	Dosage	How long have you been taking it?
Medication #1
Medication #2
Medication #3
Medication #4


Name of Evaluator:
City/State Evaluated:
Date of Evaluation:


Name of Evaluator:
City/State Evaluated:
Date of Evaluation:


Name of Evaluator:
City/State Evaluated:
Date of Evaluation:


Name of Evaluator:
City/State Evaluated:
Date of Evaluation:

Intake Questionnaire for Adult Evaluation Clients

Client Information

Education

EMPLOYMENT

INSURANCE INFORMATION

REFERAL INFORMATION

FAMILY HISTORY

Siblings

MEDICAL HISTORY