Neda Petz, Psy.D.
Neuropsychologist
Neurodevelopmental Intake Form
Your answers to these questions help me get to know you better. There are a lot of questions, so please take your time. Don't worry if you can't remember some of the information or aren't sure how to answer. However, please try and respond to all questions. If a question does not apply, please write "none" or "not applicable" so that I know you saw the question. I appreciate you taking the time to provide me with this information.
General Information
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select
Male
Female
Non-Binary/Non-Conforming
Transgender
Prefer Not to Answer
Age
Birth Date
/
Month
/
Day
Year
Date
Primary language
Please list additional languages spoken and/or written
What aspects of your cultural identity would you like me to know (e.g., race, ethnicity, religion, disability, sexual orientation, etc.)?
Purpose of the Evaluation
Please describe the reason that you are seeking an evaluation
When did you first notice these concerns?
What do you hope to learn from this assessment?
Employment
What is your employment status?
Employed
Unemployed
Retired
Self-employed
Disabled
Student
Homemaker
Other
Employer
If self-employed, name of business or type of industry
How happy are you with your career?
Not working
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not working, 10 is No Problems
Is there anything stressful about your current work?
Academic History
Highest Grade Completed:
GED
High School
Trade School
Associates
Bachelors
Masters
JD
MD
PhD
PsyD
Degree(s):
(e.g., Bachelor's in Fine Art, Master's in Education)
If currently enrolled in school, name of current school:
Average grades in grade school
Any history of
Family & Household
Including yourself, how many people live in your household?
If you have children, please complete the following section:
Please indicate if you or your immediate family members (e.g., grandparents, siblings, children) exhibit any of the following:
Family Member
Age of Diagnosis
Learning Problems
Attention Difficulties
Cognitive Difficulties
Autism
Seizure Disorder
Neurological Disorder
Genetic Disorder
Anxiety
Depression
Schizophrenia
Bipolar Disorder
OCD
Genetic Disorder
Substance Abuse / Addiction
Eating Disorder
Other
Additional Comments
How would you rate your family relationship?
Not functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not functioning, 10 is No Problems
What is you relationship status?
Married
Never Married
Separated
Domestic Partnership
Widowed
Divorced
Single
Other
How would you describe your sexual orientation?
Please Select
Heterosexual
Bisexual
Homosexual
Pansexual
Asexual
Fluid
Other
Prefer not to disclose
How would you describe your gender?
Please Select
Cisgender
Transgender
Non-Binary
Gender Fluid
Transitioning/Transitioned
Other
Prefer not to disclose
If applicable, please complete the following:
If applicable, how long have you been married?
If applicable, how long have you been in a relationship with this partner?
How would you rate your relationship with your current partner?
Not Functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not Functioning, 10 is No Problems
History
Have you previously received any type of mental health services?
Yes
No
If you answered "Yes" for the previous question, please complete the table below
Name of the therapist
Reason for seeking help
Dates of treatment
1.
2.
3.
4.
5.
Have you ever completed an evaluation/assessment before?
Yes
No
If you answered "Yes" for the previous question, please complete the table below
Name of the clinician
Reason for seeking the evaluation
Date of assessment
1.
2.
3.
Have you ever been arrested?
Yes
No
If Yes, please describe
Symptoms
Please answer all of the statements below that describe your concerns
I often experience:
fear of many things
guilt
panic attacks
avoiding people
having nightmares
anxiety, nervousness
discomfort in social situations
Other
I often experience:
Difficulty falling asleep
Difficulty getting out of bed
Difficulty staying asleep
Not feeling rested in the morning
Other
I often have:
suicidal thoughts
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts
violent thoughts
stress and tension
medical concerns
fatigue
difficulties at work
Other
I often feel:
lonely
empty
sad
hopeless about the future
excessive guilt
suspicious
Other
General Health Information
Please list psychiatric medicines that you took or are taking currently;
Are you currently under treatment for any medication conditions?
Yes
No
If you marked "yes" above, please describe
Have you ever been treated for alcohol or drug abuse?
Yes
No
If Yes, list substance(s) and treatment date
Have you used any non prescription drugs in the past 3 months?
Yes
No
If Yes, which ones
List any prior illnesses, operations, and accidents
If any of the following medical conditions apply to you, please explain below
If yes, explain what happened and when
Hospitalization
Head Injury
Seizure or convulsion
Allergies
Frequent or severe headaches
Vision problems
History of frequent ear infections
Do you have any difficulties or limitations in the following areas:
Vision
Hearing
If yes, please describe (e.g., near sighted vision is corrected with glasses)
Final Thoughts
Thank you so much for taking the time to answer these questions! We will go over your responses in greater detail and more during our first appointment.
Is there anything else that you would like me to know about you?
Submit
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