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
II. Reason for seeking evaluation at this time:
III. Client's Medical History
IV. Current Problems:
(please mark any the client is experiencing)
V. Developmental Background
If information is unknown, please leave blank.
VI. Client’s Family History
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.
VII. Client’s Education/Work History