Adult Assessment Information Packet

  • Adult Assessment Information Packet

    Please fill out the form to the best of your knowledge. If some questions are not applicable to you, write N.A.
  • Gender Identity*
  • Length of time at current residence:*
  • Type*
  • Type

  • II. Referral Information

  • Primary reason(s) for seeking assessment:*
  • Have you had a psychological assessment in the past?*

  • Which of the following are current concerns:

  • Difficulties with Attention/Concentration
  • Difficulties with Impulse Control
  • Legal Concerns
  • Difficulties with Social Life
  • Difficulties with Memory
  • Difficulties with work/academic performance
  • Depression or Anxiety

  • III. Previous Evaluations

    For each category, please list any previous evaluations, examiners, dates, and results.

  • Health

  • Date of last physical exam:
     / /

  • Psychological

  • Date of last evaluation:
     / /

  • Occupational Therapy/Physical Therapy:

  • Date of last evaluation:
     / /

  • Vision/Hearing:

  • Date of last examination:
     / /

  • Neurological:

  • Date of last examination:
     / /

  • IV. Previous Services

    Please list any previous therapy or special services you have received:
  • Dates of service:
     / /
  • Dates of service:
     / /
  • Dates of service:
     / /
  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • IV. Pregnancy

  • Any tobacco use, alcohol use, or drugs taken by the mother during pregnancy?
  • Any known health problems of mother during pregnancy?
  • Method of delivery
  • Pregnancy Length:

  • Any birth complications
  • Any problems in first few months that you are aware of?

  • IV. Developmental History

  • Motor Milestones
  • Any concerns with motor skill development (running, skipping, climbing, biking, playing ball, etc.?
  • Any fine motor difficulties?
  • Handedness:
  • Speech/Language milestones:
  • Other languages besides English growing up?
  • Do you currently speak any languages besides English?
  • Any concerns with speech problems (e.g., stuttering, difficult to understand)?
  • Any concerns with oral-motor problems (e.g., late drooling, poor sucking, poor chewing)?
  • Toileting
  • Any current concerns with bed-wetting, urine accidents, or soiling?

  • VII. Medical History

  • Rows
  • Rows
  • Have you had other special medical test (e.g., CT, MRI, EEG, etc.)?
  • Rows

  • Family Medical History 

  • Rows
  • Does any disease run in the family?

  • VIII. Behavior and Social History

  • Relationship Status:
  • Your parents are:
  • Mother/Guardian
  • Father/Guardian
  • Rows
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  • Have any of the following impacted you?

  • How often do you engage in social activities with family, friends or acquaintances?

  • Are you satisfied with your social support network?
  • Is there someone you can call when you are in distress?
  • Do you have family and/or friends that support you?
  • How often do you exercise?
  • Are you currently seeing a counselor/therapist?
  • Have you ever had thoughts/attempts to harm yourself?
  • Have you ever had thoughts/attempts to harm others?
  • Have you RECENTLY had thoughts to harm yourself and/or others?
  • Caffeine use:
  • Alcohol use:
  • Additional substance use:
  • Have the following applied to you?
  • Do you experience any problems due to cultural or ethnic issues?

  • IX. School/Occupational History

  • Current or highest level of education

  • Teachers reported problems in:
  • Did you ever participate in any testing at school?
  • Were you ever retained in one or more grades?
  • Did you ever skip a grade?
  • Did you ever receive any special services (e.g., IEP or 504 plan)?
  • What best describes your grades throughout schooling:
  • Satisfaction with employment:
  • Have you ever received disciplinary action at your job?
  • Rows

  • X. Additional Information

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  • Should be Empty: