Adult or Emerging Adult Information Form
Patient Name
*
First Name
Last Name
Patient's Name
Patient Email
*
example@example.com
Patient Phone
*
Area Code - ??? - ????
Patient Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birthdate
*
-
Month
-
Day
Year
Date
Gender
Pronouns
If in school, list
Highest grade completed
What led you to seek therapy or an evaluation now? What are your main concerns?
How do your concerns interfere with your functioning in each arena?
Rows
Never/Rarely
Sometimes
Often
Very Often
With friendships
With family members
In school
In leisure activities
In daily life activities
ability to enjoy leisure?
What might you like to change about your habits, behavior, or self?
What do you accept and like most about habits, behaviors, or self?
Are you in therapy/counseling now? In the past? Please list who you saw, and when seen.
Did your mother have problems during her pregnancy, labor, or delivery with you?
Did your mother smoke cigarettes, drink alcohol, or use drugs during her pregnancy? [Give details if yes].
Were you told you were premature or low birth weight? If you know your birth weight, write below.
Did you sit up, walk, talk at the normal age? Give details if not.
How were you described as an infant, toddler, or starting school?
quiet
active
colicky
stubborn
defiant
temper tantrums
social and friendly
Other
Did your parents divorce? Share details if relevant.
How often did you move to a new school during your childhood?
Didn't move
1-2 times
3-4 times
5 or more times
Did you have learning problems in reading, math, or writing in Elementary School?
How were your grades in Elementary School?
What comments did teachers say about you in Elementary School?
Problems getting along with others in Elementary School?
In Elementary School did you have any of the following problems?
*
Rows
Never/rarely
Sometimes
Often
Very often
Not Applicable
Talking too much
Often losing my temper
Being too aggressive or fighting
Destroying objects
Not obeying other staff or caregivers
Feeling depressed, or often lonely
Often feeling anxious, worried or scared
Being too clumsy
Loud play; often not able to be quiet
Problems organizing tasks and activities
Learning problems in reading, math, or writing in Middle School?
Grades in Middle School?
Middle School Issues or problems?
*
Rows
Never/rarely
Sometimes
Often
Very often
Not Applicable
Completing homework
Forgetting to turn in completed homework
Being truant or cutting classes.
Starting physical fights
Bringing a weapon to school
Being expelled or suspended
Running away from home overnight
Stealing
Damaging property
Losing your temper
Disobeying teachers or school staff
Breaking school rules
Setting Fires/Cruelty to animals
Often feeling depressed or lonely
Often feeling anxious, worried or scared
Bullying others
Learning problems in High School or beyond?
HIGH SCHOOL GPA
High School Issues
*
Rows
Never/rarely
Sometimes
Often
Very often
Not Applicable
Completing homework
I didn't know how to study on my own
Forgetting to turn in homework
Losing my temper too quickly
Breaking rules
Feeling depressed or lonely
Feeling too anxious or scared
My handwriting was messy or illegible
Reading seemed much harder for than classmates
I often did not know how to begin to study.
Further notes on school at any level?
FAMILY HISTORY
Rows
Mother
Father
Brother/Sister
Aunts/Uncles
Grandparents
ADHD
Reading Issues
Dyslexia
Math Issues
Handwriting
Ex Functioning
Depression
Anxiety
Social Anxiety
Mania/Bipolar
Alcohol Abuse
Drug
Abuse
Legal Issues
Hyperactivity
Inattention
OCD
Perfectionism
Tics
Anger Issues
Emotion Regulation
Psychosis
Schizophrenia
Other
Further Comments on Family?
Current stressors?
List hospitalizations, surgeries, or chronic illness you have.
Current or past MEDICAL PROBLEMS
Rows
Current
Past
allergies
heart problems
epilepsy
high blood pressure
head injury with loss of consciousness
encephalitis
brain infection
brain tumor
lead poisoning
major surgery
migraine headaches
cluster headaches
thyroid condition
vision problems
hearing problems
T1 diabetes
T2 diabetes
liver disease
tics or involuntary movements
vocal tics
persistent depression
persistent anxiety
sleep problems
eating problems
List all over-the-counter medicine, vitamins, herbs, minerals or supplements you take regularly.
How would you rate your sleep?
About how many hours of sleep do you get each night?
I don't really have any sleep issues
Sleep Issues
Rows
Never
Occasionally
2-3 times/week
>4 times/week
Does school or studying interfere with your sleep?
Does work or working late interfere with your sleep?
I have trouble falling asleep
I awaken in the night
I struggle to get back to sleep when I wake up early
I have nightmares
I have night terrors
I have done a sleep study
I have
I sleep very well
Substance use
Rows
Never
Occasionally
Weekly
Daily
>Daily
cigarettes
vape pen
caffiene
alcohol
marijuana
amphetamines (uppers, speed, stimulants)
methamphetamine (meth, crystal meth)
barbiturates (sedatives, downers)
tranquilizers (Valium, Xanax)
cocaine (coke, crack)
heroin (smack, horse)
psychedelics (LSD, ecstasy, peyote)
Further information about drug or alcohol use?
Ever assessed for ADHD? If yes, please bring the report.
Your mood most of the time lately?
cheerful/happy
sad/depressed
anxious/nervous
bland/unfeeling
angry/irritable
changes all the time
Other
Do you have temper issues?
yes
no
Other
Do your moods change often or unpredictably?
yes
no
Other
Do you have trouble making or keeping friends?
yes
no
sometimes
Other
Current Relationship?
Single
Married
Divorced
Separated
Open Relationship
Other
What's your longest relationship?
Describe your current job; title, length; satisfaction level?
What other jobs have you done?
If you are not satisfied with your job or career, what would you like to be doing?
Do you have a current driver's license?
yes
no
Other
Any problems in driving? Or keeping your license?
yes
no
Other
Number of speeding tickets since getting your driver's license?
0
1-2
3-4
>5
Number of moving violations since getting your driver's license?
0
1-2
3-4
>5
Number of speeding tickets you SHOULD have received?
Have you had arrests or convictions for legal issues? Current Issues?
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