ADHD Evaluation Intake Form

ADHD Evaluation Intake Form

I'm really happy you're here!
This intake is for a custom battery of assessments to evaluate adults for undiagnosed ADHD. A copy of all assessments taken will be sent to the client for their own records and to bring to a psychiatrist for official diagnosis.

Official diagnosis should always be done by a licensed Psychatrist or Psychologist regardless of evaluation results by ANY counselor, life coach, or trusted proffessional. This personal evaluation is not a substitute for seeing a licensed Psychiatrist or Psychologist for medical treatment and diagnosis.

Service includes initial assessment, custom battery of evaluations, copies of assessment results, 45 minute zoom session, interpretation/ sharing of results via live Zoom session, and an opporutnity to ask any questions until the end of the session.
Client Name

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Employment
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-mailHome PhoneCell Phone
Emergency Contact Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship
Medical History
NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
YesNo
YesNo
Please specify medications and/or surgeries:
AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
ADHD Symptom History

Answer to the best of your knowledge, no pressure.
Trouble finishing projectsTrouble with "Big Feelings"Trouble with PuzzlesOrganization issuesFelt misunderstoodWould over explain to gain understanding but made things worseLonlienessWhat makes other people happy doesn't work for meYelled at/punished a lot for asking questions but was told I was being disrespectful or difficult.Never understood what motivated meDoing what everyone else does makes life meaningless for meHard to find people to relate to"Night Owl"Trouble waking up in the morning/getting out of bedAnxiety when in publicCalled weird/rejected by peers and confused as to whyInterrupt people while talkingTold that you have a "bubbly" or "bright' personalityConsistent problems with understanding inferred messagesNever understood why people don't say the quiet part out loudGrew up with a feeling that you were always the one who had to "know better" and tolerate abuse.Never related to or accepted societal norms (they're dumb).Consume amounts of caffeine that shock and confuse others.
In Elementary School, what things would frustrate you?
In Elementary School, what were you really good at?
Things that make me thinkJust letting it outCBT (changing thought patterns)Creative/Art ActivitiesMindfulnessOrganization GuidanceAccountabilityI have no idea
YesNo
If Yes please share any diagnosis given by a licensed mental health professional:
Trauma History

Share as much detail as you want.
Verbal AbusePhysical AbuseSexual AbuseReligious AbuseMental AbuseWeather related TraumaComplicated GriefTraumatic Event
YesNo
Now tell me what you and google think you have.
Favorite Song Right Now:
Average hours of sleep per night
Please describe any other experiences you have had problems with
Giving me Advice/Telling me what to doToo much smiling/friendlinessCoach that is very calm/neutralOnly Logic Based SuggestionsOnly Emotionally Based SuggestionsGoal oriented problem solvingSpiritual/Faith Based Interventions (yours not mine)Interrupting me to comfort me.. (Just let me talk)Creative InterventionsInterventions that are simple and logicalOther
Silently Listening until asked a question.Comfort while speaking "That sounds so hard".Normalize my feelingsHelp me calm down with mindfulnessShare science that explains what's happeningRemind me of spiritual supportAffirmationsDon't get offended by my temporary angerOther
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

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Comprehensive Adult ADHD Evaluation
Cognitive, Executive Functioning, Emotional, Trauma, biopsychosocial evaluation

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ADHD Evaluation Intake Form

Emergency Contact Information

Medical History

ADHD Symptom History

Trauma History