AIA Psychological Pre-Assessment Form
Please complete the following Intake form to determine the best quality service experience for your child. Your Client Advocate will contact you within 24-72 hours upon completion.
Assigned Arizona Institute for Autism Case Client Advocate
First Name
Last Name
Child Name
First Name
Last Name
Gender
Child Date of Birth
-
Month
-
Day
Year
Date
Child's Age at Testing
Parent/Guardian Name
First Name
Last Name
Parent Guardian Relationship to Child
Primary Email Address
example@example.com
Secondary Email Address
example@example.com
Reason for Assessment
Please check one that applies
Family History of Alcohol/Drugs
Concerning behavioral health issues in the family
Concerning past trauma
Past sexual abuse
Physical and emotional abuse
Are there any spiritual cultural barriers that may interfere with the evaluation process?
Is there any additional information that you would like us to know?
Reason for Referral
Name of Referral
First Name
Last Name
Referral Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Email
example@example.com
What is the reason for the referral? (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Relevant Developmental History
Concerns during pregnancy (Please provide a detailed description)
Developmental milestones (Please provide a detailed description)
Social skills (Please provide a detailed description)
Emotional engagement (Please provide a detailed description)
Diet preferences (Please provide a detailed description)
Sensory sensitivities (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Psychological/Cognitive Background
Depression symptoms (Please provide a detailed description)
Anxiety symptoms (Please provide a detailed description)
Concerning thinking processes (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
School Information
School Name
Educational Placement (General Education, Special Education, Self-Contained, or others)
Grade
School Days Attending
Does the child currently have an IEP Plan?
Yes (If yes, please upload IEP Plan)
No (If no, please you're not required to upload an IEP Plan)
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Academic performance level (Please provide a detailed description)
School accommodations (Please provide a detailed description)
Classroom concentration and attention (Please provide a detailed description)
Classroom disruptive behaviors (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Speech and Language
Please check one that applies
Articulation
Unintelligible
Mumbled
Slurred
Stuttered
Clear
Rate
Normal
Slow
Verbosed
Pressured
Response Latency
Within Normal Limits
Delayed
Shortened
Is there any additional information that you would like us to know? (Please provide a detailed description)
Social Communication
Please check one that applies
Easily distracted
Difficulty in transition between activities and topics
Ability to express emotions functionally (verbally without engaging in behaviors)
Ability to make friends
Sportsmanship skills
Prefers to be alone
Does not get along with others
Is there any additional information that you would like us to know? (Please provide a detailed description)
Emotional History
Please check one that applies
Understanding feelings
Negative sense of self
Is there any additional information that you would like us to know? (Please provide a detailed description)
Client Conflict Resolution Skills/ Executive Functioning Skills
Please place a check next to any behavior or problem that client currently exhibits
Has difficulty with speech
Has difficulty with hearing
Has difficulty with language
Has difficulty with vision
Has difficulty with coordination
Is aggressive
Is shy or timid
Is more interested in things (objects) than in people
Have frequent anger bouts
Has frequent nightmares
Has trouble sleeping
Has blank starting spells
Rock back and forth
Bang Head
Eat Poorly
Engage in self-harm behavior
Is there any additional information that you would like us to know? (Please provide a detailed description)
Safety Skills
Does your child engage in any of the following behaviors?
Careful around hot/sharp objects
Aware of danger stranger
Runs into the street/parking lot
Elope from the house or in the community
Can the child ask for help in case of emergency
Is the client potty trained?
Yes
No
Please mention your safety concerns for your child. What changes you would like to see in the next 6 months? (Please provide a detailed description)
Please mention concerns while engaging in community activities with your child (e.g., difficulty at restaurants, family vacations. etc).
Is there any additional information that you would like us to know? (Please provide a detailed description)
Legal History
Previous/Current legal involvement (Please provide a detailed description)
Concerning arrests, the charges have (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Daily Living Activities
Please check all the skills your child can do independently or without any adult assistance.
Toileting
Brushing teeth
Washing hands
Dressing
Morning routine
Bathing
Is there any additional information that you would like us to know?
Type of Activity Denied Problems
Please place a check next to the daily activity where the client currently engages in Maladaptive behavior during the activity
Bathing Grooming/Hygiene
Feeding self
Dressing self
Mobility
Housework
Shopping
Managing Money
Taking Medication
Has trouble sleeping (Please provide a detailed description)
Engages in behavior that could be dangerous to self (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Substance Use History
Has a child ever used a substance? (Please provide a detailed description)
Has a child ever used a substance? (Please provide a detailed description)
How often is alcohol used? (Please provide a detailed description)
How often is a stimulant used? (Please provide a detailed description)
How often is cocaine used? (Please provide a detailed description)
How often is a tranquilizer used? (Please provide a detailed description)
How often is marijuana used? (Please provide a detailed description)
How often is opioid used? (Please provide a detailed description)
How often is hallucinogen used? (Please provide a detailed description)
How often is prescribed medication used? (Please provide a detailed description)
How often is nicotine used? (Please provide a detailed description)
How often is caffeine used? (Please provide a detailed description)
Other substances? (Please provide a detailed description)
Has the client ever received outpatient counseling for substance use issues? (Please provide a detailed description)
Has the client ever received inpatient counseling for substance use issues? (Please provide a detailed description)
Does substance use interfere with a client's life? (Please provide a detailed description)
Does substance use interfere with a client's life? (Please provide a detailed description)
Is substance use linked to criminal behavior? (Please provide a detailed description)
Is the client involved in organized activities? (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Medical History
Current medical concerns (Please provide a detailed description)
Pertinent mental health history (Please provide a detailed description)
Previous psychiatric hospitalizations (Please provide a detailed description)
Previous/current suicidal behavior (Please provide a detailed description)
Self-injurious behavior (Please provide a detailed description)
Restrictive and repetitive behaviors (Please provide a detailed description)
Inflexibility of routine (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Motor Skills
Please place a check next to any behavior or problem that client currently exhibits
Gait: Normal
Gait: Staggering
Gait: Shuffling
Gait: Slow
Gait: Awkward
Gait: Use of Cane
Please place a check next to any behavior or problem that client currently exhibits
Posture: Normal
Posture: Relaxed
Posture: Rigid
Posture: Tense
Posture: Slouched
Posture: Erect
Please place a check next to any behavior or problem that client currently exhibits
Psychomotor activity: Within normal limits
Psychomotor activity: Calm
Posture: Rigid
Posture: Tense
Posture: Slouched
Posture: Erect
Please place a check next to any behavior or problem that client currently exhibits
Psychomotor activity: Within normal limits
Psychomotor activity: Calm
Psychomotor activity: Lethargic
Psychomotor activity: Restless
Psychomotor activity: Hyperactive
Please place a check next to any behavior or problem that client currently exhibits
Mannerisms: None
Mannerisms: Tics
Mannerisms: Tremors
Mannerisms: Rocking
Mannerisms: Grimacing
Cognition Skills
Please place a check next to any behavior or problem that client currently exhibits
Thought Content: Unremarkable
Thought Content: Suspicious
Thought Content: Negative
Thought Content: Concrete
Please place a check next to any behavior or problem that client currently exhibits
Thought Process: Logical/Coherent
Thought Content: Tangential
Thought Content: Circumstantial
Thought Content: Vague
Thought Content: Loose Associations
Please place a check next to any behavior or problem that client currently exhibits
Judgment Content: Good
Judgment Content: Partial
Judgement Content: Limited
Judgement Content: Poor
Judgment Content: None
Please place a check next to any behavior or problem that client currently exhibits
Impulse Control: Good
Impulse Control: Partial
Impulse Control: Limited
Impulse Control: Poor
Impulse Control: None
Please place a check next to any behavior or problem that client currently exhibits
Insight: Good
Insight: Partial
Insight: Limited
Insight: Poor
Insight: None
Ability to following instructions (Please provide a detailed description)
Delayed recall abilities (Please provide a detailed description)
Problem solving ability (Please provide a detailed description)
Abstract thinking ability (Please provide a detailed description)
Is there any additional information that you would like us to know? (Please provide a detailed description)
Intake Acknowledgement
I hereby certify that, to the best of my knowledge, the provided information is true and accurate
Date
-
Month
-
Day
Year
Date
Parent/Guardian
First Name
Last Name
Parent/Guardian Initials
*First initial of first name/Last initial of last name
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