B
ehavioral Neuropsychology & BDTX
Adult - Personal Information Form
Name
*
First Name
Last Name
Initials
*
DOB
*
Today's Date
/
Month
/
Day
Year
Date
Who is your provider?
*
Please Select:
Dr. Antonia Forster, PhD, ABPP
Dr. Michael Fulop, Psy.D.
Dr. Kiryl Shada, Psy.D.
Dr. Justin B. Lee, PhD
Unsure
Your Home Address
Mailing Address
Street Address Line 2
City
State
Zip
Your Preferred Phone #
*
Your Preferred email address
example@example.com
If in school/college, tell us which one
Grade or level
Relationship Status
Please Select
Single
Married
Never Married
Living As Married
Student
Divorced
Prefer not to answer
If involved in a religion, which?
Who referred you to us at BDTX?
Phone # of person who referred you
What problems might you want to address or change?
Have you ever had a psychological assessment? What was unhelpful and helpful about it?
List of psychiatrists, psychologists, counselors, social workers, or mental healthcare providers you see now, or have seen in the past
Elementary School Education
What problems, if any, did you have in Elementary School? [All that apply]
No Problems
Reading
Learning to Read
Mathematics
Spelling
Writing
Memory
Coordination
Handwriting
Foreign Language
Executive Skills
Organizational Skills
Paying Attention in Class
Paying Attention Home
Long-Term Projects
Completing Homework
Procrastination
Test Anxiety
Behavior Problems
Other
Please explain further how you struggled in Elementary School
Did you have a 504 plan or an IEP in Elementary School?
Please Select
YES
NO
I DON'T RECALL
What accommodations did you get in Elementary School?
Please Select
None
Extended time on tests
Extended time on homework
Low-Distraction Test Taking Room
All of the above
I don't recall
Other
Middle School Education
What problems, if any, did you have in Middle School? [All that apply]
No Problems
Reading
Learning to Read
Mathematics
Spelling
Writing
Memory
Coordination
Handwriting
Foreign Language
Executive Skills
Organizational Skills
Paying Attention in Class
Paying Attention Home
Long-Term Projects
Completing Homework
Procrastination
Test Anxiety
Behavior Problems
Other
Please explain further how you struggled in Middle School?
Did you have a 504 plan or IEP in Middle School?
Please Select
YES
NO
I DON'T RECALL
What accommodations did you get in Middle School?
Please Select
None
Extended time on tests
Extended time on homework
Low-Distraction Test Taking Room
All of the above
I don't recall
Other
High School Education
What problems, if any, do you recall having in High School? [All that apply]
No Problems
Reading
Learning to Read
Mathematics
Spelling
Writing
Memory
Coordination
Handwriting
Foreign Language
Executive Skills
Organizational Skills
Paying Attention in Class
Paying Attention Home
Long-Term Projects
Completing Homework
Procrastination
Test Anxiety
Behavior Problems
Other
Please explain what you struggled with in High School?
Did you have a 504 or IEP in High School?
Please Select
YES
NO
I DON'T RECALL
What accommodations did you get in High School?
Please Select
None
Extended time on tests
Extended time on homework
Low-Distraction Test Taking Room
All of the above
I don't recall
Other
High School Graduation Date:
/
Month
/
Day
Year
Date
High School GPA:
What Activities did you do in your school years [clubs, church, activities, sports, etc]
College and or Grad School Education
What problems, if any, do you recall having in College/Grad School? [All that apply]
No Problems
Reading
Learning to Read
Mathematics
Spelling
Writing
Memory
Coordination
Handwriting
Foreign Language
Organizational Skills
Paying Attention in Class
Paying Attention Home
Long-Term Projects
Completing Homework
Procrastination
Test Anxiety
Behavior Problems
Other
Please explain how you struggled in College or Grad School?
Did you get accommodations in college or grad school?
Please Select
None
Extended time on tests
Extended time on homework
Low-Distraction Test Taking Room
All of the above
I don't recall
Other
College Graduation Date
/
Month
/
Day
Year
Date
College Major/Overall GPA
Employment History
What is your current job?
What is stressful about your present job?
Current Employment: How satisfied are you with your present job?
No Satisfaction
1
2
3
4
Highly Satisfied
5
1 is No Satisfaction , 5 is Highly Satisfied
List other jobs you've had
Your Health History
Date of last physical exam
/
Month
/
Day
Year
Date
Who is your primary care provider?
What are your current or longer term health concerns?
What medications do you take?
What supplements do you take?
Have you ever used tobacco? Smoked, Chewed? If you quit, when?
Have you ever used drugs? Please list
Your Family History
Please check whether any relatives have had any of these problems. If yes, please specify in the next text box.
Mothers's Family
Father's Family
Mental Health Problems
Learning Issues
Alcohol or Drug Abuse/Dependence
Intellectual Disability
Legal Problems
Inattention Issues
Hyperactivity
Anxiety Problems
Obsessions and or Compulsions
Perfectionism
Tics or Involuntary Movements
Anger Problems
Psychiatric Hospitalizations
Language or Speech Problems
Depression
Bipolar Disorder
Mood Problems
Emotion Regulation
Please explain about anything you checked above
Check any issue or problems you are currently experiencing:
Alcohol Use/Abuse
Behavior Regulation
Drug Use/Abuse
Excessive Video/Gaming
Memory Issues
Obsessions or Compulsions
Tics
Procrastination
Anger Management
Learning Issues
Excessive Activity
Legal Issues
Mood Regulation
Organizational Problems
Psychiatric Problems
Anxiety Problems
Depression
Inattention
Work Related Problems
Medical Regimen Adherence
Perfectionism
Sleep
Financial Problems
Other
Use this space to explain further anything you checked above [if desired]
Your Personal Strengths
Important values in your life
How do you usually cope with stress?
Driving
How many speeding tickets have you received since obtaining your license?
Please Select
0
1-2
3-4
5-6
>6
Number of moving violations or accidents you've had since obtaining your license?
Have you ever had your license restricted, revoked, or suspended?
Please Select
Yes
No
Other
Explain driving issues further
Your Future
What would you like to be different for you in 6-12 months from now?
What would you like to be different for you in 2 years from now?
What would you like to be different for you in 5 years from now?
Did we miss information you would like us to know about you?
What are your main goals for this assessment or treatment?
Please verify that you are human
*
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