Your Initials *

Your Name *

Your Email *

Your Phone *

Date of Birth *

Reason for requesting an assessment *

Have you had a previous psychological or educational evaluation? *

Please describe your current living situation:

Have you been to the doctor in the past year? If so, how is your current health? Are you being treated for anything? *

Have you had both hearing and vision screenings in the past year? Please describe: *

Please describe any medical or physical problems you have had: *

Are you currently taking medication, either prescription or over the counter? If yes, carefully list the specific medication and dose date first prescribed, who prescribed, and for what purpose: *

Please list any medications you have taken in the past, and the reason for the prescriptions: *

Were there any problems or unusual circumstances during your mother’s pregnancy or your delivery? If yes, please describe: *

Were you adopted? (please choose) *

Were there any developmental problems including delay in learning to crawl, walk, or talk? If yes, please describe: *

As a child, were you extremely physically active or always “on the go”? *

Please provide a comprehensive school history, including name/type of schools attended as well as current school/grade level if applicable: *

Please describe any of the following problems you have experienced, including the time of onset for each:

Reading difficulty, writing difficulty, mathematics difficulty, poor grades, homework problems, peer problems, and/or organizational problems: *

Please describe your greatest strengths and any special abilities or talents. What school subjects have you generally done best in? *

What problems, if any, do you have with fears, tension, anxiety, panic attacks, phobias, being uncomfortable in new situations, or shyness? How has this changed over time? *

What problems, if any, do you have with self-esteem? Are there particular things you are most likely to feel bad about? *

Do you have any problems with sleep? If yes, please describe: *

Please identify any blood relatives (i.e. “Dad’s brother”) who have or had learning or psychological difficulties of any kind:

Is there anything else it would be helpful to know about?