Adult - Personal Information Form
Behavioral Neuropsychology, LLC
Who is your provider?
Antonia Forster, PhD, ABPP
Michael Fulop, PsyD
Greg Cox, PhD
Alisa Karmel, PsyD, MScN
Your zip code
Your Preferred Phone #
Your Preferred email address
Living As Married
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 had a previous psychological assessment? What was helpful/unhelpful?
List ANY current or former psychiatrists, psychologists, counselors, social workers, or other mental healthcare providers.
If in school/college, tell us which one
Current Grade or level
Elementary School Education
What problems, if any, did you have in school at any level [All that apply]
I don't recall
What problems, if any, did you have in Elementary School? [All that apply]
Learning to Read
Attention in Class
Attention @ Home
Provide details: In what grade did the problems start? How did they resolve?
Did you have a 504 plan or IEP in Elementary, Middle, High School, College?
I DON'T RECALL
What specific accommodations did you receiver at any level of school: Elementary, Middle, High School or College?
Extended time on tests
Extended time on homework
Low-Distraction Test Taking Room
All of the above
I don't recall
Extra-curricular activities you were in during any school years [such as clubs, church, hobby, sports...]
High School GPA:
High School Graduation Date:
College Graduation Date
College Major/Overall GPA
Looking back at your school years, what do you REGRET doing or not doing ?
Vocational & Employment History
What is your current job?
What is stressful about your present job?
What do you enjoy about your present job?
Current Employment: How satisfied are you with your present job?
1 is No Satisfaction , 5 is Highly Satisfied
List other jobs you've had
What is your ideal job or vocation?
Your Health & Your Personal Concerns
Date of your last physical exam
Who is your primary care provider?
What current or long-term health concerns do you have?
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
Ever had school, legal, or job issues due to drugs or alcohol use or abuse? If so, list.
Check any issue or problems you are currently experiencing:
T1 Diabetes Issues
T2 Diabetes Issues
Obsessions or Compulsions
Not Listening Well
Making or Keeping Friends
Work Related Problems
Medical Regimen Adherence
Excessive Screen Time
If needed, add details about your health or personal concerns.
How many speeding tickets have you had since first obtaining a driver's license?
How many moving violations/accidents you've had since your first driver's license?
Have you ever had your license restricted, revoked, or suspended?
Explain driving issues further
Your Family History
Please check if any of these relatives have or have had any of these problems. If yes, please specify in the next text box.
Mental Health Problems
Alcohol or Drug Abuse/Dependence
Obsessions and or Compulsions
Tics or Involuntary Movements
Language or Speech Problems
If needed, add details about your family history or family concerns.
Your Strengths, Values & Your Future
Your Personal Strengths...
Important Values in Your Life...
What do you do to cope with stress?
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?
What are your main goals for this assessment or treatment?
Did we miss information you would like us to know about you?
Should be Empty: