Adult - Personal Information Form
Behavioral Neuropsychology, LLC
Who is your provider?
*
Please Select:
Antonia Forster, PhD, ABPP
Michael Fulop, PsyD
Greg Cox, PhD
Alisa Karmel, PsyD, MScN
Unsure
Your Name
*
First Name
Last Name
Your DOB
*
Your zip code
Your Preferred Phone #
*
Your Preferred email address
example@example.com
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 had a previous psychological assessment? What was helpful/unhelpful?
List ANY current or former psychiatrists, psychologists, counselors, social workers, or other mental healthcare providers.
Educational History
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]
Please Select
No problems
I don't recall
What problems, if any, did you have in Elementary School? [All that apply]
Reading
Learning to Read
Mathematics
Spelling
Writing
Memory
Coordination
Handwriting
Foreign Language
Executive Skills
Organizing Skills
Attention in Class
Attention @ Home
Long-Term Projects
Do Homework
Procrastination
Test Anxiety
Behavior Issues
Other
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?
Please Select
YES
NO
I DON'T RECALL
What specific accommodations did you receiver at any level of school: Elementary, Middle, High School or College?
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
Extra-curricular activities you were in during any school years [such as clubs, church, hobby, sports...]
High School GPA:
High School Graduation Date:
/
Month
/
Day
Year
Date
College Graduation Date
/
Month
/
Day
Year
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?
No Satisfaction
1
2
3
4
Highly Satisfied
5
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
/
Month
/
Day
Year
Date
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:
Alcohol Use/Abuse
T1 Diabetes Issues
T2 Diabetes Issues
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
Not Listening Well
Making or Keeping Friends
Work Related Problems
Medical Regimen Adherence
Perfectionism
Excessive Screen Time
Sleep problems
Financial Problems
Vocational Problems
Driving Problems
Other
If needed, add details about your health or personal concerns.
How many speeding tickets have you had since first obtaining a driver's license?
Please Select
0
1-2
3-4
5-6
>6
How many moving violations/accidents you've had since your first driver's license?
Please Select
0
1-2
3-4
5-6
>6
Have you ever had your license restricted, revoked, or suspended?
Please Select
Yes
No
Other
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.
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
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?
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