Clinical Intake

Welcome to Your Psychological Evaluation Intake Form

Thank you for taking the time to share your story with us. We've designed this intake form to help Dr. Long get to know you better before your evaluation. You might notice that we ask for quite a bit of detail about different parts of your life – this is because understanding your full life story helps us provide the most accurate and helpful evaluation possible.

Why so detailed? Well, each person's experiences, from childhood to present day, shape who they are. When we understand your unique journey, we can better understand your current situation and provide more meaningful insights and recommendations.

A Few Friendly Notes:
- This form typically takes about an hour to complete
- You can save your progress and come back to it later
- Feel free to skip any questions you'd prefer to discuss in person with Dr. Long
  There's no pressure to share anything you're not comfortable with
- Your privacy is important to us - everything you share is confidential (with a few exceptions that we'll discuss during your session)
The more you feel comfortable sharing, the better we can help, but remember - you're in control of what you want to tell us. Take your time, and if you have any questions along the way, just make a note and we can discuss them when we meet.

Ready to begin? Just remember to grab a comfortable seat and maybe your favorite beverage - we're going to be learning a lot about your life journey together.

Need a break? No problem! You can save your progress and come back anytime. And if something doesn't apply to you, just write "N/A" - we'd rather know that than wonder if you missed a question.
First Name Only
Last Name Only
Birthday*

MonthDayYear
Date
Age *
What is your preferred pronoun *
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Your Email*
example@example.com
What are your main reasons for seeking this psychological evaluation?*
What current life circumstances or challenges would you like us to be aware of?*
Childhood Family History
Do you know of any health issues or complications when you were born?*

YesNo
Please provide details about any complications or issues that occurred during your birth or your mother's pregnancy.*
What was your parents' relationship status during your childhood? If there were any significant changes, how did these impact you?*
How would you describe your relationship with your dad growing up*
How would you describe your relationship with your mom growing up?*
What kind of work did your parents do when you were a child?*
Do you have any brothers or sisters? Tell us about them and how you get along*
How would you describe your overall childhood?*
If you think back to when you were a kid, how would you describe yourself? *
Adverse Childhood Experiences (ACEs) Expanded

Please select 'yes' or 'no' for each of the following experiences if they occurred before your 18th birthday:

	Y/N
Physical abuse - Being physically hurt by a parent or other adult, like being kicked, punched, or beaten up.
Emotional abuse - Being regularly insulted, put down, yelled at, or made to feel worthless by parents or other adults.
Sexual abuse - Being forced into sexual contact or activities by an adult or older child.
Physical neglect - Not having basic needs met like adequate food, clothing, or supervision.
Witnessing domestic violence - Seeing parents or guardians physically harming each other.
Emotional neglect - Not receiving love, support, or feeling valued and cared for by family members.
Household substance abuse - Living with someone struggling with alcoholism, drug addiction, or substance abuse issues.
Household mental illness - Having a household member with depression, mental illness, attempted suicide, or psychiatric problems.
Parental separation/divorce - Parents separating, divorcing, or one parent being absent from the home.
Incarcerated household member - A parent, guardian, or other household member going to jail or prison.
Bullying - Being frequently bullied, harassed, or mistreated by peers or adults.
Community violence - Experiencing or witnessing violence in one's neighborhood or community.
Discrimination/racism - Encountering discrimination or racist attitudes based on one's race, ethnicity or culture.
Unsafe neighborhood - Living in a neighborhood that feels unsafe due to crime, violence, or other threats.
Forced displacement - Having to move/relocate due to factors like natural disasters, war, housing issues.
Medical trauma - Undergoing a medical procedure or illness that was traumatic.
Natural disaster/war exposure - Directly experiencing events like earthquakes, floods, wars, or combat.
Poverty/economic hardship - Experiencing poverty, homelessness, lack of basic needs due to financial issues.
Death of parent/sibling - Losing a parent or sibling during childhood.
Foster care involvement - Being raised in foster homes or the foster care system.

Education
Were you ever tested for or struggled with any potential learning disabilities, like dyslexia, dysgraphia, or have an IEP Plan, etc., during your years in school?*

YesNo
Can you expand on what learning disabilities or struggles you experienced in school? What was the outcome of any testing or evaluations you had?*
Did you graduate from high school or obtain an equivalent diploma?*

YesNo
Did you go to college or a trade school ?*

YesNo
Have you ever faced disciplinary action such as in-school or out-of-school suspension, expulsion, or academic probation in an educational institution?*

YesNo
Please explain each instance of disciplinary action. *
Work History
What is your current job title, employer, and estimated salary or Hourly? If you are not currently employed, please explain why.*
What are the types of jobs you've had in the past?*
Medical History:
Are you currently prescribed to any medications?*

YesNo
List each medication you are currently taking. Click on the "Plus" sign below to add additional medications. *
Please describe any significant medical conditions, illnesses, or physical health issues you have experienced. This may include chronic diseases, injuries, surgeries, or other medical events that have impacted your physical health. Mental health and substance abuse will be addressed in the following section.*
Mental Health History:
Have you ever received mental health services or treatment from a primary care provider, specialist, or any other healthcare professional? Additionally, are you currently or have you previously taken any medication specifically for mental health purposes?*

YesNo
For each mental health provider you've seen in the last 5 years, please list the provider's name, indicate if you're still seeing them, their contact number, and the reason (e.g., anxiety, depression, ADHD, therapy, medication). After detailing one provider, click the "Plus" sign below to input information for the next provider.*
List any mental health conditions you've been diagnosed with, whether you agree with them or not, from the past or present. *
Have you ever been hospitalized voluntarily or involuntarily for mental health reasons or placed under a 24-hour hold due to mental health concerns?*

YesNo
Please provide details of any previous voluntary or involuntary hospitalizations for mental health reasons, including the facility name and the name of the doctor or caseworker, if possible.*
List all prior psychological evaluations. ( Type of evaluation, Name of Provider, Year)*
What medication's have you been prescribed for mental health reasons in the past but are no longer taking?*
Family Mental Health History
Has anyone in your family been diagnosed with or treated for:

Bipolar disorderDepressionAnxietySuicideSchizophreniaPost-traumatic stressSubstance AbusePersonality DisordersOther
List each family member (relation to you) and what mental health condition did they have. Click on the "Plus" sign to add additional family members*
Substance Abuse History
Have you ever had a substance abuse assessment or been in any alcohol and drug treatment programs, including inpatient and/or outpatient or sober living?*

YesNo
Please list the name of any drug/alcohol treatment program you attended, the name of your primary counselor/provider, the year you went, and how long you were there.*
Have you attended any 12-step programs or support groups regarding recovery?*

YesNo
Please discuss any involvement you've had with 12-step programs like Alcoholics Anonymous or Narcotics Anonymous, or other support groups related to recovering from drug and alcohol addiction. Describe your experience with these groups, including how frequently you attended meetings, your role or participation level, and what impact, if any, the groups had on your recovery process.*
Have you ever been or are you currently currently in recovery from drug and alcohol abuse?*

YesNo
In your own words, what does being 'in recovery' from substance abuse mean to you? How would you describe the recovery process and what it entails based on your personal experience? Is your recovery abstinence-based both from all drugs and alcohol?*
Check the box of any drug you've tried in the past*

MethamphetamineCocaine Powder/CrackSynthetic Marijuana or D8,D9Heroin/ FentanylLSD or HallucinogensMarijuanaPain killers (not as prescribed)MethadoneTranquilizer/sleeping pillsAlcoholEcstasy MDMABenzodiazepine (xanax,valium,)Never done a drug in my lifeKratomketamineAny designer drugs or research chemicalsOther
Legal History
As a juvenile or an adult, have you ever been arrested, charged, indicted, or taken into custody.*

YesNo
Please list all arrests and any supporting information (e.g., charges, outcomes, relevant dates). Use plus sign for each incident.*
Support Systems and Home Environment
A Social support system is a network of people – friends, family, and peers – that we can turn to for emotional and practical support in times of need. Please describe who is in your support network and how they can help.*
Could you describe any hobbies, passions, social groups, community organizations, or religious groups you are involved with?*
Current Relationships
Are you currently in a relationship?*

YesNo
Please tell me about your relationship, including how you met, what it is like, and anything else you think is important.*
Since you're currently not in a relationship, are you open to dating or pursuing a new relationship? If you are, could you share what kind of relationship you're interested in or the qualities you're looking for in a partner? If you're not looking for a relationship, could you tell me why you enjoy being single or why you've chosen to take a break from relationships?*
Your Family
Do you have any children, including biological, adopted, or stepchildren?*

YesNo
For each of your children and stepchildren, please provide their Name, Age, and Gender, and the name of the other parent. After your first entry, if you have more children to add, use the plus sign (+add child) as necessary.*
Describe your relationship with each of your children. What do you enjoy doing together, and are there any challenges or conflicts? Are you in regular contact with them? Additionally, what would you say are their individual strengths and weaknesses*
Have any of your children experienced birth complications or developmental delays? If so, please describe them in detail.*

YesNo
Please describe any delays or complications in detail*
Is there anything specific you'd like your evaluator to know or understand about you before beginning this process?*
Should be Empty:

Childhood Family History

Adverse Childhood Experiences (ACEs) Expanded

Education

Work History

Medical History:

Mental Health History:

Family Mental Health History

Substance Abuse History

Legal History

Support Systems and Home Environment

Current Relationships

Your Family