Patient Intake History

Patient's Legal Name*

First NameLast Name

Name of Person Completing Form (LEAVE BLANK if same as Patient Legal Name)

First NameLast Name

Are you the person's caretaker?

YesNo

Relationship to Patient

Caretaker Name*

First NameLast Name

Caretaker Email*

example@example.com

Caretaker Mobile Number*

Is the person listed as the caretaker also the patient's emergency contact?

YesNo

Please Enter Emergency Contact Name

First NameLast Name

Please Enter Emergency Contact Number

Please enter a valid phone number.

Patient's Preferred Name (if different than legal name)

First NameLast Name

Patient Email*

example@example.com

Patient Mobile Number*

Preferred Pronouns

Date of Birth

Date

Patient Age

Gender at Birth

MaleFemale

Highest Level of Education of Current Grade

Race

Ethnicity

Handedness

Right-handedLeft-handedOther

If other, specify

If left-handed: Other left-handed family members?

YesNo

If yes, specify who in the family is left-handed?

First language learned and spoken fluently?

Second language learned and spoken fluently? (if applicable)

Currently, what is the patient’s primary language?

Referral Source

The patient is being evaluated due to difficulties with (check all that apply):

Cognitive Functioning/Developmental DelayBehavioral Regulation/Inattention/HyperactivityMood SymptomsSocial Functioning/Concern for Autism Spectrum Disorder

Please explain

Is the assessment related to a disability application or ongoing disability claim?

YesNo

Is the assessment in relation to legal or financial matters (e.g., pending litigation, financial benefit considerations)

YesNo

Is the patient’s primary insurance Medicaid?

YesNo

Is the patient seeking solely psychotherapy services, without an interest in neuropsychological assessment?

YesNo

Current Medications (please specify the date if any medications were added or changed within the past 4 months)

Past Medications

In the following section, please indicate any past or present treatment or therapy interventions the patient has undergone. It is important to include details such as the dates, duration of the intervention, and response to the treatment. These details should be included in the Notes column.

None

Psychotropics

CurrentPastNA

Notes

(e.g., age started)

Psychotherapy

CurrentPastNA

Notes

(e.g., age started)

School counseling

CurrentPastNA

Notes

(e.g., age started)

Psychiatric hospitalization

CurrentPastNA

Notes

(e.g., age started)

ECT (Electroconvulsive Therapy)

CurrentPastNA

Notes

(e.g., age started)

Speech therapy

CurrentPastNA

Notes

(e.g., age started)

Occupational therapy

CurrentPastNA

Notes

(e.g., age started)

Physical therapy

CurrentPastNA

Notes

(e.g., age started)

Cognitive rehabilitation

CurrentPastNA

Notes

(e.g., age started)

ABA or behavioral therapy

CurrentPastNA

Notes

(e.g., age started)

Social skills group

CurrentPastNA

Notes

(e.g., age started)

Early intervention

CurrentPastNA

Notes

(e.g., age started)

IEP (Individualized Education Program)

CurrentPastNA

Notes

(e.g., age started)

504

CurrentPastNA

Notes

(e.g., age started)

FBA/BIP school behavior plan

CurrentPastNA

Notes

(e.g., age started)

Other school services or accommodations

CurrentPastNA

Notes

(e.g., age started)

Tutoring

CurrentPastNA

Notes

(e.g., age started)

Patient Neurological History

If other, specify:

Additional information:

Family Neurological History

Non-ContributoryUnknown

Notable for:

If other, specify

Additional Information

Patient Psychiatric History

NoneUnknown

Notable for:

If other, specify

Is the patient non-verbal (not to be confused with selective mutism)?

YesNo

Does the patient have down syndrome?

YesNo

Additional information

Family Psychiatric History

NoneUnknown

Notable for:

If Other, specify

Patient Medical History

NoneUnknown

Cancer

If Other, specify

Cardiac

If Other, specify

Dermatologic

If Other, specify

Oral Disorders

If Other, specify

Patient Intake History

General Information

I. Patient Information

II. Referral Information

Additional info:

Section III to be completed internally by clinician. Patient to skip to section IV.

IV. Medications

V. Treatments, Therapies, and Interventions

Treatment/Therapy Type

Section VI to be completed internally by clinician. Patient to skip to section VII.

VII. Past Neurological, Psychiatric and Medical History

---END---Sections VII queries and VIII to be completed internally by clinician.