Welcome to Quince Orchard Psychotherapy.

Our goal is to answer your questions for testing comprehensively and clearly, and to provide useful recommendations to you for future directions in addressing any challenges.

The following questionnaire contains important questions regarding history and development that will be useful to us in beginning your assessment. Please fill this out to the best of your ability, and bring it with you to your first meeting with the testing clinician. If you are unable or uncomfortable answering any of these questions, please leave them blank.

We also ask that you provide copies of any previous testing reports, IEPs, and other documents that will be useful to us in this testing, on your first visit with your testing clinician.

Please do not hesitate to ask us any questions before, during, or after the testing process. Thank you for choosing Quince Orchard Psychotherapy for your assessment needs. We look forward to working with you.

Sincerely,

Carrie Singer, Psy.D.Director, Quince Orchard Psychotherapy

Alex Smith, Psy.D. Assessment Supervisor, Quince Orchard Psychotherapy

GENERAL INFORMATION:

Name of Person Completing this form: ___________________________________

Name of Person Being Tested: ________________________________________

Please answer these questions for the person being tested. Use the back of the page for extra space when needed.

Date of Birth: ___________________ Age: __________

Home Address: ____________________________________________________

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Phone number: _________________________

Email address: _________________________________

Name of Insurance Plan: ______________________________________________________________

Insurance member ID number: _______________________________________________________

Relationship to primary insured: _____________________________________________________

Have you checked to see if a pre-authorization is required for testing or if a

deductible applies?: ___________________________________________________________________

Who referred you to our office? ________________________________________________________

Gender: _______________________________________

Ethnicity: _______________________________________

Religion (if applicable) :__________________________________________

Sexual orientation: _______________________________________________

Please describe the problems you are having, and what type of services you are seeking from us for these problems.

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PARENTS/GUARDIANS:

Mother’s Name__________________________________________________________

Date of Birth: _____________ Age: ___________

Occupation: _______________________________

Employer: ________________________________

Education Completed__________________

Father’s Name__________________________________________________________

Date of Birth: _____________ Age: ___________

Occupation: _______________________________

Employer: ________________________________

Education Completed__________________

Marital Status: If divorced, who has physical custody? __________ Is it full or joint? __________ Who has legal custody? __________ Is it full or joint? __________

If child is adopted, from where and at what age?:__________________________________

If adopted, what is known about the biological family history?:

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Does either parent’s job require him/her to be away from home long hours or extended periods?___________________

If married, how long have you been married? ____________________________

If divorced, how long have the biological parents been divorced? ___________________

Is there a birth parent living outside the home: (circle one) MOTHER FATHERName:_____________________________

Where do they live?_______________________

Please give any other information about you or your child’s living arrangement that you think we should know.

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Siblings:

First Name Age Do they get along?

1. _________________ ______ ___________________

2. _________________ ______ __________________

3. _________________ ______ __________________

4. _________________ ______ __________________

Please indicate any special needs of concerns regarding the other children living in

your home:

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Do you have any concerns about how your child interacts with siblings/friends, or parents?

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Others: List any other people who currently, or in the child’s lifetime, have lived in your home.

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PSYCHOLOGICAL HISTORY:Is there a history in your immediate or in the mother’s or father’s extended family, of the following, and if so who?Yes No Who

___ ___ Autism Spectrum Disorders __________________________

___ ___ Learning Problem/Disabilities __________________________

___ ___ ADHD – ADD- Attention Problems __________________________

___ ___ Depression or Mood Disorder __________________________

___ ___ Behavior Problems in School __________________________

___ ___ Anxiety Disorders (OCD, Phobias, etc.) __________________________

___ ___ Mental Retardation __________________________

___ ___ Psychosis/Schizophrenia __________________________

___ ___ Substance Abuse/Dependence __________________________

___ ___ Other Mental Health Concern __________________________

Has the child you are seeking services for been evaluated in the past? Yes/NoIf Yes, please list the following information on the previous evaluation(s): Who Type When 1. ______________________ ____________________ _______________

2. ______________________ ____________________ _______________

3. ______________________ ____________________ _______________

4. ______________________ ____________________ _______________

If yes, what were their general findings and recommendations?

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Has your child, to your knowledge, been exposed to traumatic events (the loss of a loved one, a natural disaster, etc.) or been subject to abuse or neglect (physical, verbal, sexual, or emotional)? Please describe:

Please provide us with any other information on the psychological history that you

feel would be helpful to us:

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PRE-NATAL AND DELIVERY HISTORY:

Did the birth mother receive regular pre-natal care? Y/N

Were there any complications with the Pregnancy? Y/N

If Yes, please provide details of complications, and treatment during pregnancy:

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Was birth at Full Term? Y/N

If No, please provide details:

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Type of Delivery: Spontaneous/Induced Vaginal/C-Section

Complications? Y/N

If Yes, please provide details of complications during birth: _________________________________________________________________________________________________

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Birth Weight: ____lbs ____oz

Concerns at Birth? Y/N

If Yes, please provide details – including any treatments given:

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Is there any additional pre-natal or birth information that might be of assistance to us?

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Has your child ever had a fever above 104°? Yes NoIf yes, Please explain: ________________________________________________________________________

Has your child ever had a seizure of unexplained period of unconsciousness? Yes NoIf yes, Please explain:

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Has your child ever had a head trauma or blow to the head that cause unconsciousness or required a medical review?If yes, Please explain:

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DEVELOPMENTAL HISTORY:

1. Were there any difficulties during infancy (e.g. colic, poor feeding, excessive crying)? If yes, please explain:

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2. Did you child have any attachment/bonding issues before the age of 5? If yes, please explain:_________________________________________________________________________________________________

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3. Please indicate the age at which your child did the following:

Rolled Over consistently ______________

Sat up unsupported ______________

Stood ______________

Crawled ______________

Walked Unassisted ______________

Said 1st Word Intelligible to strangers ______________

Said two-three word phrases ______________

Used Sentences regularly ______________

Toilet trained during the day ______________

Dry through the night ______________

Dressed Self ______________

4. Please indicate if your child is experiencing any of the following:

Problems with eating __________

Isolated socially from peers __________

Problems making friends __________

Problems keeping friends __________

Problems getting to sleep __________

Problems controlling temper __________

Trouble waking up __________

Fatigue/tiredness during the day __________

Nightmares __________

Bed wetting __________

Soiling __________

Problems with authority __________

Anxiety __________

Unmotivated __________

Stress from conflict between parents __________

Legal situation (anyone in the family) __________

History of abuse __________

Alcohol/drug use/abuse __________

School concentration difficulties __________

Grades dropping or consistently low __________

Sadness or Depression __________

5. List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child has had.

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6. List any medications your child is currently taking or has taken for extended periods (give dates and dosage level, if possible): ________________________________________________________________________

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7. Child’s current height: ______Ft. ______Inches Weight: ______Lbs.

8. With which hand does the child write? ______________________________________

9. Does the child have any vision problems? ___________________________________

Please list date of last vision test: ________________________________________________10. Does the child have any hearing problems? _________________________________

Please list date of last hearing test:_______________________________________________

11. Name of child’s pediatrician: ___________________________________________________

Phone Number: _________________________

Name of child’s Psychotherapist: _______________________________________________________

Phone Number: _________________________

Name of child’s Psychiatrist:__________________________________

Phone number:_____________________________________

(Please list information on additional Physicians on the back of the page.)

EDUCATIONAL HISTORY:1. List in chronological order all schools your child has attended:Name Grade(s) Areas of concern

______________________________________ _____________ ______________________________________

______________________________________ _____________ _____________________________________

______________________________________ _____________ ______________________________________

______________________________________ _____________ ______________________________________

2. Please list two current teachers of two different subjects (example: English and

Math) and their contact info:

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3. Does your child’s teacher have concerns about him/her? Please list:

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4. What is your child’s favorite subject/class? ____________________________________________

5. What is your child’s least preferred subject/class? ____________________________________

6. Has your child ever repeated a grade? Y/N If yes, what grade(s)?:________________________

7. If your child has been in Special Education, did they have a:☐ 504 Plan ☐ I.E.P.☐ Psychological Evaluation ☐ Speech Evaluation☐ Behavior Intervention Plan ☐ Occupational Therapy Evaluation☐ Physical Therapy Evaluation ☐ Adaptive Technology Evaluation☐ Other(s):

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8. If your child has been in Special Education, how were they served?

☐ Consultation ☐ Resource Classroom☐ Collaborative Education ☐ Team Taught Classes☐ Pull-Out ☐ Self-Contained Classroom

☐ Special Program ☐ Psychoeducational Center

9. Child’s extracurricular activities, including sports, clubs, hobbies, lessons, etc.:

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10. List any special abilities, skills, strengths your child has:

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SYMPTOM CHECKLIST:

Please check any items that you currently notice any issues with:

Problem Solving:______ Difficulty figuring out how to do new things______ Difficulty planning ahead______ Difficulty figuring out problems that most other people can do______ Difficulty thinking as quickly as needed______ Difficulty doing things in the right order (sequence problems)______ Difficulty verbally describing the steps involved in doing something______ Difficulty changing a plan or activity in a reasonable amount of time______ Difficulty doing more than one thing at a time______ Difficulty switching from one activity to another activity______ Easily frustrated

Speech, Language, Academics:______ Difficulty finding the right word to say______ Difficulty understanding what others are saying______ Unable to speak______ Difficulty staying with one idea______ Difficulty writing letters or words (not due to motor problems)______ Slurred speech______ Odd or unusual speech sounds______ Difficulty with math (e.g., checkbook balancing, making change, etc.)______ Difficulty understanding/remembering what is read______ Difficulty spelling

______ Difficulty following directions

Concentration and Awareness:______Highly distracted______Lose train of thought easily______Problems concentrating______Become easily confused or disoriented______Blackout spells (fainting)______Mind goes blank______Don’t feel very alert or aware of things

Memory:______Forgetting where they leave things (e.g., backpack, coat, etc.)______Forgetting names______Forgetting what they should be doing______Problems finding their way around places I have been to before______Forgetting where they are or where they are going______Not aware of time (i.e., time of day, season, year)______Forgetting time of day______Forgetting events that happened quite recently (e.g., last meal)______Forgetting events that happened long ago (months or years)______Need someone to give them a hint to remember things______Forgetting the order of things (e.g., when doing a chore, etc.)______Forgetting facts______Forgetting how to do things, but can remember facts______Forgetting faces of people they know (when they are not present)______Frequently forgetting assignments

Motor/Coordination:______Difficulty doing things they should automatically be able to do (e.g.,brushing teeth, combing hair, etc.)______Problems drawing or copying______Difficulty dressing______Decline in musical abilities______ Writing is not readable, or is very small or large______Slow reaction time______Walking more slowly than other people______Balance problems______Difficulty starting to move______Often bumping into things______Fine motor control problems (pencil, keys, games, etc.)

______Muscles tire quickly

Sensory: ______Loss of sense of taste______Difficulty tasting food______Difficulty telling right from left______Difficulty looking quickly from one object to another object______Difficulty recognizing objects or people______Need to squint or move closer to see clearly______Double vision______See unusual things______Blurred vision (Left, Right, Both Eyes)______Blank spots in vision (Left, Right, Both Eyes)______Brief periods of blindness (Left, Right, Both Eyes)______See "stars" or flashes of light (Left, Right, Both Eyes)______Loss of vision (Left, Right, Both Eyes)______Problems seeing on one side (Left side, Right Side, Both)______Loss of feeling or numbness (Left side, Right Side, Both)______Tingling or strange skin sensations (Left side, Right Side, Both)______Pins and needles (Left side, Right Side, Both)______Difficulty telling hot from cold (Left side, Right Side, Both)______Loss of feeling (Left side, Right Side, Both)______Burning skin(Left side, Right Side, Both)______Parts of body seem as if they do not belong to them (Left side, Right Side, Both) ______Losing hearing (Left, Right, Both Ears)______Deaf (Left, Right, Both Ears)______Hear unusual things (Left, Right, Both Ears)______Ringing in ears or hearing strange sounds (Left, Right, Both Ears)______Unaware of things on one side of body

Behavior:

______Sadness or depression______Anxiety or nervousness______Stress______Sleeping problem: [ ] falling asleep [ ] staying asleep______Become angry more easily______Euphoria (feeling on top of the world)______More emotional (e.g., cry more easily)______Loss of interest

______Change in attitudes______Doing things automatically (without awareness)______Less inhibited______Difficulty being spontaneous______Change in eating habits

Please provide us with any other information that you feel would be helpful to us:

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Thank you for taking the time to complete this