Child Intake Form

Hope and Inspiration Psychological Services
Child Intake Form: Diagnostic Psychological Evaluation

For parents or guardians of children ages 4 to 11. Please complete all sections to help us understand your child's needs. All information is confidential.
Consent and Confidentiality
Child's Full Name

First NameLast Name
Child's Preferred Name / Nickname
Child's Date of Birth

MonthDayYear
Date
Child's Age
Child's Gender
Child's Grade / School
Primary Language(s) Spoken at Home
Parent / Guardian Name(s)
Relationship to Child
Parent / Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Email
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for Referral
What concerns led you to seek a psychological evaluation for your child?
Who referred your child for the evaluation (for example, school, doctor, yourself)?
Developmental History
Were there any complications during pregnancy, birth, or early childhood?
At what age did your child reach major milestones (walking, talking, toilet training)?
Does your child have a history of developmental delays or disabilities?
Medical and Therapy History
Past and current medical conditions or allergies
Current medications (including supplements)
Previous hospitalizations or surgeries
Vision or hearing problems
Current therapy services (for example, counseling, occupational, speech, or physical therapy)
Activities of Daily Living (ADLs)
Can your child dress, bathe, and feed themselves independently? If not, what help do they need?
Does your child need help using the bathroom?
¿Puede su hijo mantener su higiene personal (por ejemplo, cepillarse los dientes, lavarse las manos)?
Sleep and Eating Habits
Typical bedtime and wake-up time
Sleep quality / nighttime problems (for example, difficulty falling or staying asleep, nightmares, night terrors, sleepwalking)
Appetite and usual eating habits
Concerns about picky eating, overeating, or unusual eating behaviors
Sensory Concerns
Unusual sensitivity to sounds, lights, textures, tastes, or smells
Avoiding clothing, foods, or situations because of sensory issues
Hobbies and Interests
Activities, games, or hobbies your child enjoys
Participation in sports, arts, clubs, or extracurricular activities
Educational History
Current school and grade
Has your child repeated or skipped a grade?
Special education services or accommodations (IEP, 504 plan)
Academic strengths and challenges
Behavioral, Emotional, and Social Concerns
Behavior problems (tantrums, aggression, hyperactivity, withdrawal)
Mood/emotional concerns (sadness, anxiety, excessive fears)
Self-harm, suicidal thoughts, or homicidal ideation
Impulsive or unsafe behaviors (running away, climbing, dangerous stunts)
Problems with the law or school authorities
Social Functioning
How your child relates to siblings and peers
Social skills / interaction with others (for example, making and keeping friends, interacting with adults)
Household Tasks and Responsibilities
Household tasks or responsibilities your child has
How your child handles these responsibilities
Family History
Family members with learning, behavioral, or mental health concerns
Who lives at home with the child
Previous Evaluations and Interventions
Previous psychological, educational, or speech-language evaluations
Counseling, occupational, speech, or physical therapy received
Goals for the Evaluation
What do you hope to learn or achieve from this evaluation?
Additional Information
Is there anything else you would like us to know about your child?
Should be Empty:

Hope and Inspiration Psychological Services

Child Intake Form: Diagnostic Psychological Evaluation

Consent and Confidentiality

Reason for Referral

Developmental History

Medical and Therapy History

Activities of Daily Living (ADLs)

Sleep and Eating Habits

Sensory Concerns

Hobbies and Interests

Educational History

Behavioral, Emotional, and Social Concerns

Social Functioning

Household Tasks and Responsibilities

Family History

Previous Evaluations and Interventions

Goals for the Evaluation

Additional Information