Adult Intake

1
Adult Intake Form

Please tell us a little more about your concerns so we can better understand your needs for testing. If you have difficulties with this form, please call our office at 828-231-3297

This form will take you approximately 15 minutes to complete, and is comprised mainly of checklists, allowing you to scan and complete quickly.

The information submitted in this form is guaranteed to be kept confidential and secure. Please wait for the confirmation page to appear once you submit your form.
2
General Client Information* This field is required.
Client's Name (First & Last)
Preferred Name
Client's Date of Birth
Male
Female
Other
Biological Sex/Gender
Client's Age
English
Spanish
Russian
Chinese
French
Arabic
Other
Primary Language
3
Please tell us about the client's biological sex and preferred gender :
4
Contact Information* This field is required.
Name of person completing this form
Self
Spouse
Partner
Biological Parent
Adoptive Parent
Step Parent
Grandparent
Guardian
Other
Relation to client
Your Email address
Your Physical Address
Your Phone number
Email
Phone
Preferred Method of Contact
Your Occupation or Student
Your Place of Employment or School
5
Client Contact Info
Client's Name
Client's Physical Address
Client's Email address
Client's Phone number
Occupation or Student
Place of Employment or School
6
Financial Guarantor
Name of Financial Guarantor
Self
Spouse
Partner
Biological Parent
Adoptive Parent
Step Parent
Grandparent
Guardian
Other
Relation to Client
Client is own legal guardian
I'm client's legal guardian
I have healthcare power of attorney
Other legal guardian or POA
Legal Guardian
Financial Guarantor's Phone Number
7
Please explain legal guardianship or POA
Huge
Large
Normal
Small
Ok
Ok
8
Do you want to list another contact person (a second parent, another support person, etc?)
YESNO
9
Contact Information (Second Person) * This field is required.
Person's Name
Spouse
Partner
Biological Parent
Adoptive Parent
Step Parent
Grandparent
Guardian
Other
Relation to client
Email address
Physical Address
Phone number
Email
Phone
Preferred Method of Contact
Occupation or Student
Place of Employment or School
10
Is there any legal action underway? (e.g. civil suit, legal guardianship, criminal charges, custody, etc.) * This field is required.
YESNO
11
Please explain the legal action that is currently underway. 
12
Referral Information
Who referred you to CReATE or how did you hear about us?
Yes
No
Not Applicable
Do you want us to have contact with your referral source?
Referral source's contact information or N/A
Was the client referred to a specific psychologist at CReATE?
If yes, please list the name of the psychologist
13
Briefly describe the reason for referral, concerns, or a little about the client's current difficulties:
14
What would you like to learn from this evaluation?
15
How long have these concerns/difficulties been present?
16
Areas of concern :* This field is required.(check all that apply)
ADD/ADHD or attentional concerns
Autism Spectrum concerns
Anxiety or Mood concerns
Mental health concerns (or psychiatric)
Personality or Clinical concerns
Substance use concerns
Dyslexia or reading concerns
Dyscalculia or math concerns
Dysgraphia or writing concerns
General learning/processing concerns
Behavioral concerns
None
17
Areas of concern :* This field is required.(check all that apply)
Traumatic Brain Injury (TBI)
Epilepsy/Seizure Disorder effects
Concussion with loss of consciousness
Brain Aneurysm
Concussion without loss of consciousness
Brain or spinal tumor
Major illness (cancer, lupus, MS, etc.)
Fetal Alcohol Effects
Other Brain related concerns
None
18
Attention* This field is required.(check all that apply)
Frequently misses details or makes careless errors
Difficulty following instructions
Easily distracted
Difficulty sustaining attention over time
Avoids tasks that require sustained attention
Difficulty listening when spoken to
Loses things often
Difficulty listening with distractions present
Forgetfulness
None
19
Activity Level* This field is required.(check all that apply)
Acts impulsively (without thinking)
Physically active or hyperactive
Slow or sluggish (hypoactive)
Daydreams or seems "spaced out"
Difficulty sitting still for long
Fidgety or restless
Interrupts others often
Talks too much
Has difficulty waiting his/her turn
None
20
Processing Speed * This field is required.(check all that apply)
Difficulty making decisions quickly
Difficulty following conversations
Difficulty remembering new information
Requires more time to complete tasks
Difficulty getting started on tasks
Difficulty completing tasks
Slow to take in information
Slow to respond
Overwhelmed by too much information
None
21
Executive Functioning * This field is required.(check all that apply)
Difficulty following multi-step directions
Difficulty switching from an activity to another
Inflexible thinking
Difficulty organizing thoughts / actions
Difficulty organizing belongings
Difficulty with time management
Difficulty prioritizing tasks
Difficulty planning ahead
Difficulty with problem-solving
None
22
Nonverbal / Visual-Spatial * This field is required.(check all that apply)
Difficulty with hands-on tasks
Difficulty with sequencing familiar tasks
Right / Left confusion
Difficulty copying information
Difficulty driving
Difficulty recognizing mistakes
Difficulty reading maps/graphs
None
23
Memory * This field is required.(check all that apply)
Difficulty remembering to do things
Difficulty remembering family member's names
Difficulty remembering dates
Forgets needed or important items
Gets lost easily
Frequently misplaces items
Forgets newly learned information
Forgets to take medications
Forgets to eat a meal
None
24
Coordination / Motor Function * This field is required.(check all that apply)
Difficulty with handwriting
Problems with coordination or balance
Difficulty buttoning shirt or tying shoelaces
Loss of coordination
Loss of strength
Shuffling feet
Slowness of movements
Weakness in hands, arms, legs, etc.
Chronic fatigue
Hand tremor
Involuntary movements
Dizziness
Awkward gait
None
25
Language * This field is required.(check all that apply)
Receptive (i.e. understanding what is said)
Expressive (i.e. using words to communicate)
Difficulty finding the right word
Only wants to talk about one or two things
Perseverates on certain subjects
Word substitution errors
Recites or echoes phrases
Difficulty deciphering the meanings of words
Literal interpretation of language
Difficulty with back and forth conversation
Word Salad (e.g. sequences of random words)
None
26
Speech * This field is required.(check all that apply)
Articulation difficulties
Unusual speech volume (too loud or soft)
Stuttering
Repetitive speech or sounds
Halting / irregular speech pattern
Unusual tone or prosody
Slow/plodding speech
Rapid or pressured speech
Slurring of speech
None
27
Behavior * This field is required.(check all that apply)
Makes poor decisions
Behaviorally Dysregulated
Becomes upset if routine is changed
Is inflexible / stubborn
Physically Aggressive (toward others)
Destruction of Property
Disappearing for long periods
Legal Problems
Compulsive behavior
Self-injurious behavior
Disciplinary infractions
None
28
Social Relationships * This field is required.(check all that apply)
Has difficulty initiating social interactions
Socially isolated
Feels rejected by others
Loss of significant relationship
A lot of conflict in relationships
Socially anxious
Has intense and short-lived relationships
Difficulty maintaining relationships
Poor boundaries in relationships
None
29
Social Skills * This field is required.(check all that apply)
Does not read social cues well
Does not understand jokes, literal
Timing seems off when interacting with others
Poor eye contact
Difficulty understanding perspective of others
Was bullied or teased when younger
Has only a few narrow interests
Gullible or naïve
Bullies or teases others
Socially awkward
None
30
Sensory* This field is required.(check all that apply)
Auditory (sensitive to loud or certain sounds)
Tactile (sensitive to textures such as clothing)
Visual (aversion to or fascination with lights)
Olfactory (heightened sense of smell)
Loss of sense of smell
Change of sense of smell
Unexplained bad odors
Loss or change of sense of taste
Strong food preferences/aversions
High or low tolerance for pain
Easily overstimulated in general
None
31
Perceptual * This field is required.(check all that apply)
Visions or visual hallucinations
Hearing voices (auditory hallucinations)
Hearing unexplainable or strange sounds
Hearing ringing or buzzing noises
Tingling in body (hands, arms, feet, legs, etc.)
Blurring blindness or double vision
Intolerance or over sensitivity to light
Facial numbness, pain, or drooping
Sudden laughing / crying
None
32
Sleeping * This field is required.(check all that apply)
Difficulty settling for sleep at night
Hypersomnia (sleeping more than usual)
Insomnia
Snoring or waking suddenly for air
Sleep walking or talking
Nighttime bed wetting
Recurrent nightmares
Night terrors
Decreased need for sleep
None
33
Eating * This field is required.(check all that apply)
Limited food choices
Recent weight gain
Unintended weight loss
Intended weight loss
Frequent headaches
Frequent stomachaches
Changes in Appetite
Abdominal Pain
Restrictive eating
Binging/Purging
None
34
Physical * This field is required.(check all that apply)
Breathing problems / wheezing
Dizziness or fainting
Enuresis (poor bladder control)
Encopresis (bowel control)
Frequent headaches
Constipation
Migraine headaches
Loose stools
Tics
Sexual Dysfunction or Problems
Chronic or Acute Pain
None
35
Mood * This field is required.(check all that apply)
Low self-esteem
Sadness or confusion about gender
Poor self-confidence
Easily angered / irritable
Feeling sad / blue / depressed
Has increased energy
Feeling anxious / stressed / worried
Suspiciousness / Paranoia
Has decreased energy
Has specific phobias
Often emotionally dysregulated
Suicidal ideation
Feels guilty
Withdrawn
Easily startled
None
36
Trauma* This field is required.(check all that apply)
Physical abuse
Emotional abuse
Sexual abuse or sexual assault
Accident or injury
None
Other
37
Thoughts * This field is required.(check all that apply)
Racing Thoughts
Mental rituals
Unusual thoughts
Preoccupations
Disruptive thoughts, memories, or "flashbacks"
Obsessions (e.g. intrusive thoughts)
Thoughts of harming self
Compulsions (e.g. mental rituals)
Thoughts of harming others
Phobias
Violent fantasies
Recurrent thoughts of death
Fears of hurting others
None
38
Adaptive behavior * This field is required.(check all that apply)
Difficulty getting self dressed
Difficulty completing daily tasks independently
Difficulty with toileting
Difficulty with feeding
Difficulty maintaining clean hygiene
Difficulty with nighttime or morning routine
None
39
Description for any items checked (Optional):
40
Were any of these concerns/difficulties the result of a known event/injury (e.g., brain injury, seizure, illness etc.)?* This field is required.
Yes
No
41
If Known Event, please check all that apply:
Brain Injury (TBI)
Stroke
Brain Aneurysm
Seizures
Brain or Spinal Tumor
Trauma/Stressor/Transition
Concussion with loss of consciousness
Substance Use/Overdose
Concussion without loss of consciousness
Psychiatric event (e.g. hospitalization)
Major Illness (cancer, lupus, MS, etc.)
Other
42
Which of the following scans/tests have previously been performed?(check all that apply)
CT scan
Metabolic Panel (e.g., blood work)
MRI
Chest X-Ray
EEG
PET Scan
Urinalysis
MEG Scan
None
43
If you would like to upload any medical records, please click the "Browse Files" button below and choose a file from your computer (if not applicable, please skip):
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
44
Previous schools attended
Name of School (High school, college, etc.)
City
Graduated
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Name of School (High school, college, etc.)
Row 0, Column 0
City
Row 0, Column 1
Graduated
Row 0, Column 2
Name of School (High school, college, etc.)
Row 1, Column 0
City
Row 1, Column 1
Graduated
Row 1, Column 2
Name of School (High school, college, etc.)
Row 2, Column 0
City
Row 2, Column 1
Graduated
Row 2, Column 2
Name of School (High school, college, etc.)
Row 3, Column 0
City
Row 3, Column 1
Graduated
Row 3, Column 2
Name of School (High school, college, etc.)
Row 4, Column 0
City
Row 4, Column 1
Graduated
Row 4, Column 2
1 of 5
45
Educational Placement and Prior Services* This field is required.(check all that apply)
Public School
Private School
Regular classes
504 Plan
Special Education Classes (IEP)
Tutoring
Home school
Attendance Diploma Only
GED
None
46
Reading* This field is required.(check all that apply or none)
Was diagnosed with dyslexia
Struggled learning to read
Received tutoring for reading
More difficulty learning to read than expected
Difficulty sounding out or decoding words
Poor tracking
Frequent word reading errors
Difficulty reading fluently or smoothly
Poor comprehension
Reads slowly
Reading seems lower than verbal/oral abilities
Tires easily when reading
Difficulty completing longer reading passages
Does not grasp main ideas or key concepts
Overhwhelmed by the volume of reading
None
47
Math* This field is required.(check all that apply or none)
Was diagnosed with math learning disability
Always struggled with math
Received tutoring for math
Poor arithmetic calculation
Poor understanding of math concepts
Tires easily when working math
Difficulty recalling previously learned concepts
Poor number sense
Difficulty learning math facts
Difficulty understanding more complex math
Difficulty with geometry or spatial math
None
48
Writing* This field is required.(Check all that apply or none)
Was diagnosed with writing disability
Always struggled with handwriting
Received tutoring for writing
Letter reversals
Poor spelling
Difficulty getting thoughts on paper
Writing is laborious, arduous
Difficulty organizing sentences/paragraphs
Poor use of grammar in writing
Writing below expectation of verbal abilities
Poor punctuation, capitalization
Difficulty completing writing assignments
Difficulty getting started on essays or papers
Does not know how to keyboard efficiently
Difficulty communicating through writing
None
49
Prior Testing* This field is required.(check all that apply)
School-based testing
Neuropsychological Evaluation
Psychoeducational Evaluation
Psychological Evaluation
Speech-Language Evaluation
OT Evaluation
QEEG/SPECT
None
50
Please upload any previous psychological/psychoeducational testing that would be relevant to the client's assessment at CReATE (if not applicable, please skip):
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
51
Prior Learning or School Diagnoses (Previously diagnosed elsewhere)
ADHD or "ADD"
Learning Disorder or disabilty
Autism Spectrum Disorder or Asperger’s
Intellectual Disability
None
Other
52
Known health problems in biological mother during pregnancy(check all that apply)
Pre-eclampsia/Toxemia
Hypertension/High Blood Pressure
Gestational Diabetes
Blood (RH) Incompatibility
Injury/Accident
Illness/Fever
Anemia (low iron)
Emotional strain/Trauma
Fertility Treatment
Postpartum Depression
Mental illness
Don't know
None
Other
53
To the best of your knowledge, did the biological mother smoke, drink alcohol, or use drugs while pregnant with the client?* This field is required.
No
Yes
Don't Know
Suspected
54
Birth History * This field is required.(check all that apply and enter Birth Weight)
Domestic adoption
Foreign adoption
Full-term (38-42 weeks gestational age "GA")
Mild Prematurity (3 weeks early, 37 GA)
Moderate preterm (4-7 weeks early, 33-36 GA)
Very preterm (8-12 weeks early, 28-32 GA)
Extremely preterm (12+ weeks premature)
Late-term (42+ weeks GA)
C-section
Breech position
Forceps
Cord around neck
Don't know
Other
55
Neonatal History* This field is required.(check all that apply)
Breathing problems
Meconium staining
Low Apgar Score (< 7)
Lacking oxygen
Multiple births
Birth defects noted
Admitted to NICU
Drug withdrawal
Sent home on apnea monitor (CPAP)
Colic
Failure to thrive
Hospitalization
Seizures/convulsions
Don't know
None
Other
56
Early Development* This field is required.(check all that apply)
Delayed language development
Regressed in language skills
Had repetitive language or echolalia
Delayed motor development
Low Muscle Tone
Flapping hands or movements, rocking
Resisted physical activity
Delayed in learning to feed or dress self
Delayed in potty training
Lined up toys or played with parts of toys
Problems in preschool
Very active or hyperactive
Received early intervention
Did not enjoy cooperative/imaginative play
Don't Know
None
57
Medical Information
Name of PCP and Practice
Approximate Date of Last Visit
Yes
No
Were vision and hearing screenings normal?
If no, please explain
Yes
No
Are the client's immunizations up to date?
If no, please explain
58
Neurologic(check all that apply)
Brain Injury
Concussion
Loss of Consciousness
Brain Aneurysm
Migraines
Movement Disorders
Brain or Spinal Tumor
Stroke
Seizures/Epilepsy
Dementia
Narcolepsy
Sleep Disorder
None
59
Eyes, Ear, Nose, & Throat* This field is required.(check all that apply)
Chronic Ear Infections
Tubes in ears
Strep Throat
Tonsils or adenoids removed
Swallowing Disorder
Asthma
Seasonal Allergies
Dizziness (e.g., vertigo, BPPV)
Macular degeneration
Cataracts or Glaucoma
None
Other
60
Cardiovascular * This field is required.(check all that apply)
High or Abnormal Blood Pressure
High Cholesterol
Heart Disease
Blood disease (e.g. anemia)
Arteriosclerosis
Heart attack
Other heart related surgery
None
61
Endocrine* This field is required.(check all that apply)
Diabetes (Type 1 or Type 2)
Hypoglycemia
Hyperthyroidism (e.g. Graves Disease)
Parathyroid Disorder
Adrenal Gland Disorder (e.g. Addison's)
Kidney Disorder
Cushing's Syndrome
Low Testosterone
Menopause
None
62
Genital-Urinary & Gastrointestinal* This field is required.(check all that apply)
Bowel or Bladder Incontinence
Colon Disease (e.g., Chron’s, IBS)
Regular Urinary Tract Infections
Gastroesophageal Reflux Disease (GERD)
Pancreatitis
Liver Disease (e.g., hepatitis)
Enuresis or encopresis
None
63
Muscular-Skeletal* This field is required.(check all that apply)
Cerebral Palsy
Amputation
Arthritis
Degenerative Joint Disease
Osteoporosis
Fibromyalgia
Broken bones
Physical Abnormality
Chronic Fatigue Syndrome
None
64
Oncology/Hematology* This field is required.(check all that apply)
Breast cancer
Prostate cancer
Cervical cancer
Ovarian cancer
Pancreatic cancer
Skin cancer
Colon cancer
Lung cancer
Brain Tumor
Leukemia
Lymphoma
Sickle cell anemia
Hemophilia
Myeloma
None
65
Genetic or Acquired* This field is required.(check all that apply)
Fragile X
Down Syndrome
Mitochondrial Disease
Lead poisoning
Toxic exposure
Physical injuries
None
66
Neurodevelopmental (previously diagnosed)(check all that apply)
ADHD or "ADD"
Learning Disorder
Autism Spectrum Disorder or Asperger's
Intellectual Disability
None
67
Infectious Disease * This field is required.(check all that apply)
Meningitis
Encephalitis
HIV
Tuberculosis
COVID-19 Infection
None
68
Description of any of the items above (Optional):
69
Is the client prescribed or taking any medications or alternative medicines or supplements?* This field is required.
Yes
No
70
Medication/Supplements
Name of Medication/Supplement
Past Use
Current Use
Dosage/Frequency
Purpose
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
1
2
3
4
5
Name of Medication/Supplement
Row 0, Column 0
Past Use
Row 0, Column 1
Current Use
Row 0, Column 2
Dosage/Frequency
Row 0, Column 3
Purpose
Row 0, Column 4
Name of Medication/Supplement
Row 1, Column 0
Past Use
Row 1, Column 1
Current Use
Row 1, Column 2
Dosage/Frequency
Row 1, Column 3
Purpose
Row 1, Column 4
Name of Medication/Supplement
Row 2, Column 0
Past Use
Row 2, Column 1
Current Use
Row 2, Column 2
Dosage/Frequency
Row 2, Column 3
Purpose
Row 2, Column 4
Name of Medication/Supplement
Row 3, Column 0
Past Use
Row 3, Column 1
Current Use
Row 3, Column 2
Dosage/Frequency
Row 3, Column 3
Purpose
Row 3, Column 4
Name of Medication/Supplement
Row 4, Column 0
Past Use
Row 4, Column 1
Current Use
Row 4, Column 2
Dosage/Frequency
Row 4, Column 3
Purpose
Row 4, Column 4
1 of 5
71
Mental Health (previously diagnosed)* This field is required.(check all that apply)
Anxiety Disorder
Depressive Disorder
Bipolar Disorder
Psychotic Disorder (e.g. Schizophrenia)
PTSD
Substance Use Disorder
Eating Disorder
Obsessive Compulsive Disorder
Phobias
Personality Disorder
Conduct Disorder or Behavioral Disorder
None
72
Treatment History(check all that apply)
Outpatient therapy
Psychiatric Monitoring/Treatment
Psychiatric Hospitalization
Psychopharmacological Treatment
Partial Hospitalization
Intensive Outpatient Program (IOP)
Residential Treatment
Substance Use Treatment
Rehabilitative Center
Rehabilitation Outpatient
Physical Therapy
Neurofeedback
Speech language therapy
Occupational therapy
None
Other
73
Does the client have a history of substance use?* This field is required.
YESNO
74
Substance Use
No Use
Only Rarely
Current Use
Past Use
Frequency
Date of Last Use
Unknown
Alcohol
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Marijuana
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Cocaine
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Heroin
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
MDMA (e.g. Ecstasy)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Hallucinogenics (e.g. LSD, "Acid")
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Prescription Pain (Opiates)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Prescription Anxiolytic (Valium, Xanax, etc.)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
Other
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Alcohol
Marijuana
Cocaine
Heroin
MDMA (e.g. Ecstasy)
Hallucinogenics (e.g. LSD, "Acid")
Prescription Pain (Opiates)
Prescription Anxiolytic (Valium, Xanax, etc.)
Other
No Use
Row 0, Column 0
Only Rarely
Row 0, Column 1
Current Use
Row 0, Column 2
Past Use
Row 0, Column 3
Frequency
Row 0, Column 4
Date of Last Use
Row 0, Column 5
Unknown
Row 0, Column 6
No Use
Row 1, Column 0
Only Rarely
Row 1, Column 1
Current Use
Row 1, Column 2
Past Use
Row 1, Column 3
Frequency
Row 1, Column 4
Date of Last Use
Row 1, Column 5
Unknown
Row 1, Column 6
No Use
Row 2, Column 0
Only Rarely
Row 2, Column 1
Current Use
Row 2, Column 2
Past Use
Row 2, Column 3
Frequency
Row 2, Column 4
Date of Last Use
Row 2, Column 5
Unknown
Row 2, Column 6
No Use
Row 3, Column 0
Only Rarely
Row 3, Column 1
Current Use
Row 3, Column 2
Past Use
Row 3, Column 3
Frequency
Row 3, Column 4
Date of Last Use
Row 3, Column 5
Unknown
Row 3, Column 6
No Use
Row 4, Column 0
Only Rarely
Row 4, Column 1
Current Use
Row 4, Column 2
Past Use
Row 4, Column 3
Frequency
Row 4, Column 4
Date of Last Use
Row 4, Column 5
Unknown
Row 4, Column 6
No Use
Row 5, Column 0
Only Rarely
Row 5, Column 1
Current Use
Row 5, Column 2
Past Use
Row 5, Column 3
Frequency
Row 5, Column 4
Date of Last Use
Row 5, Column 5
Unknown
Row 5, Column 6
No Use
Row 6, Column 0
Only Rarely
Row 6, Column 1
Current Use
Row 6, Column 2
Past Use
Row 6, Column 3
Frequency
Row 6, Column 4
Date of Last Use
Row 6, Column 5
Unknown
Row 6, Column 6
No Use
Row 7, Column 0
Only Rarely
Row 7, Column 1
Current Use
Row 7, Column 2
Past Use
Row 7, Column 3
Frequency
Row 7, Column 4
Date of Last Use
Row 7, Column 5
Unknown
Row 7, Column 6
No Use
Row 8, Column 0
Only Rarely
Row 8, Column 1
Current Use
Row 8, Column 2
Past Use
Row 8, Column 3
Frequency
Row 8, Column 4
Date of Last Use
Row 8, Column 5
Unknown
Row 8, Column 6
1 of 9
75
Substance use has contributed to(check all that apply)
Feeling guilty or ashamed
Inability to live independently
Criticism from significant others
Failing or performing poorly in school
Loss of significant relationships
Loss of job or difficulty holding down a job
None
Other
76
Please list names of any current treatment providers or others involved in the client's care (therapist, psychiatrist, neurologist, etc.)
77
Have any family members been diagnosed with following?Age Related Diseases
Alzheimer's
Dementia
Parkinson's
Huntington's
Pick's
None
Don't know
78
Have any family members been diagnosed with following?* This field is required.Neurodevelopmental
ADHD or "ADD"
Dyslexia or Reading LD
Dysgraphia or Writing LD
Dyscalculia or Math LD
Language Disorder
Autism Spectrum Disorder or Asperger’s
Intellectual Disability
Learning difficulties of unknown origin
None
Don't know
79
Have any family members been diagnosed with following?* This field is required.Mental Health
Anxiety Disorder
Depressive Disorder
Bipolar Disorder
Psychotic Disorder (e.g., Schizophrenia)
Substance Use Disorder
Eating Disorder
Obsessive Compulsive Disorder
Phobias
Personality Disorder
Conduct Disorder or Behavioral Disorder
None
Don't know
80
For any Family History items checked, please list the family member's relation to the client (e.g., parent, sibling, cousin, etc.)
81
Client's Current Living Arrangement(check all that apply)
Alone
With spouse or partner
With parents
With roommate
With children
With another relative
With a caregiver
In a group home
Satisfied with current living arrangement
Dissatisfied with current arrangement
At risk of becoming homeless or losing housing
82
Client's Employment (check all that apply)
Satisfied with current job or lack of job
Dissatisfied with current job or lack of job
Satisfied with educational status
Dissatisfied with educational status
83
Education(check all that apply)
Some high school
High school graduate
GED
Some college
College graduate
Master's Degree
PhD
MD
JD
Other Advanced Degree
84
Early Life Stressors (check all that apply)
Adoption
Foster care
Neglect or inadequate care as child
Physical abuse as child
Emotional abuse as child
Sexual abuse as child
Residential instability
None
85
Psychosocial or Family Stressors:* This field is required.(check all that apply)
Family financial stressors
Marital discord / conflict
Impending divorce
Domestic violence
Sexual assault
Difficult move
Difficult transition
Residential instability
Legal problems (self)
Legal problems of partner
Asked to leave job or school
Neglect or inadequate care
Parental rights terminated
Recent loss of loved one
Recent loss of significant relationship or friendship
None
86
Please list client's strengths (hobbies, interests, achievements, positive traits, etc.)
Strengths and Positive Traits:
Hobbies and Interests:
Extracurricular Activities:
Achievements:
87
Thank you for completing this form. The information submitted is guaranteed to be kept confidential and secure. We will be in touch regarding options for testing, pricing, and scheduling soon. Please be patient as we review each intake form to make the best recomendations for the client.
Should be Empty: