Initial Information for Testing Services for Amy Maus

Client's First Name(Required)

Client's Last Name(Required)

Name of person completing this form:(Required)

Person completing this form is:(Required)

self

parent

other

If person completing this form is other, please explain:

Instructions: Please answer the following questions about the client. If you are completing this form for your child, please answer each question in regard to your child, not to yourself.

I. Basic Information

Today's Date(Required)

Age(Required)

Date of Birth(Required)

Client's race/ethnicity(Required)

Home Phone #(Required)

Cell Phone #(Required)

Please check if we may leave messages at your:(Required)

Home Phone

Cell Phone

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address(Required)

Referred by:

II. Reason for seeking evaluation at this time:

Please describe.(Required)

III. Client's Medical History

Has the client ever been previously evaluated for mental health or learning concerns, by a school, mental health clinician, medical professional or anyone else?(Required)

Yes

Please list any previously diagnosed mental health conditions and/or learning disabilities.(Required)

Date of last physical exam/"well child" exam:(Required)

Please list all of the client’s current prescription medications and the name of the prescribing doctor(s):(Required)

Please list all of the client’s previous (non-current) medications for mental health concerns:(Required)

Has the client previously seen a professional for counseling / therapy?(Required)

Yes

If yes, please provide the name of the professional and approximate dates of treatment:(Required)

IV. Current Problems:

(please mark any the client is experiencing)

Current Problems(Required)

Please list any additional concerns not mentioned above:

V. Developmental Background

If information is unknown, please leave blank.

Client's parents are:

biological

adopted

other

If other, please explain:

Length of pregnancy:

Any major complications during pregnancy:

Alcohol/drug/tobacco use by mother during pregnancy:

Type of delivery:

Health of client at delivery:

Early Temperament:

Age at which the client began walking:

Age at which the client was toilet trained:

Early speech (please note any concerns or delays with early speech/language):

Has the client ever experienced seizures?

Yes

Has the client ever experienced tics or involuntary movements?

Yes

Has the client every experienced a head injury?

Yes

Has the client ever been exposed to lead?

Yes

If yes on any of the above 4 questions, please describe:

Date of most recent vision exam and results:

Date of most recent hearing exam and results:

Other relevant illness, injuries or physical disabilities:

Concerns regarding the client's sleeping or eating:

Concerns regarding social skills/experiences/behaviors:

Concerns regarding motor skills (gross or fine):

Extra-curricular activities / Hobbies / Talents:

VI. Client’s Family History

Mother's Name

First Last

Age

Occupation

Health

Quality of Relationship

Is the Client's Mother Deceased?

Yes

Cause of Death

Age at Death

Client's Age at the Death

Father's Name

First Last

Age

Occupation

Health

Quality of Relationship

Is the Client's Father Deceased?

Yes

Cause of Death

Age at Death

Client's Age at Death

Spouse's Name:

First Last

Age

Occupation

Health

Quality of Relationship

Is Client's Spouse Deceased?

Yes

Cause of Death

Age at Death

Client's Age at Death

Client’s parents are (or were, If Deceased):

Married

Divorced

Never Married

Living Together

Separated

NOTE: If the client is a minor and parents are separated or divorced, both parents must sign consent for the evaluation unless otherwise indicated in the court ordered parenting plan. A copy of the court’s parenting plan MUST accompany this form to the initial interview session.

If applicable, information regarding custody and/or legal parenting plan:

Please list step-parents and other parental figures:

Names and ages of client's siblings:

Names and ages of client’s children:

Please list all biological family history of mental health or learning concerns on the paternal side:

Please list all biological family history of mental health or learning concerns on the maternal side:

Please list all biological family history of mental health or learning concerns within siblings:

VII. Client’s Education/Work History

Is the client still in school?(Required)

Yes

School

School's Phone Number

Name of School Contact Person

First Last

Current Grade or Level

Recent Grades/Performance

Typical grades/performance:

Onset of performance changes:

Academic strengths:

Academic weaknesses:

Please describe all special services currently received at school:

Behavioral concerns at school:

Concerns noted by teacher(s):

Length and difficulty of homework; homework routine:

Educational Level Obtained

Please describe challenges experienced in school:

Please list any special education services received during school:

Current Employer and Position

Length of Current Employment

Job Satisfaction level (1-Low, 5-High):

Emergency Contact

Please let us know who we can call in case of an emergency.

Emergency Contact Name:(Required)

First Last

Emergency Contact Phone #:(Required)

Initial Information for Testing Services for Amy Maus

Initial Information Form for Testing Services for Amy Maus, MSW, LCSW

I. Basic Information

II. Reason for seeking evaluation at this time:

III. Client's Medical History

IV. Current Problems:

V. Developmental Background

VI. Client’s Family History

VII. Client’s Education/Work History

Emergency Contact