Preliminary Diagnostic Interview
Full legal name:
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Birthdate:
MM
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DD
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YYYY
Email:
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Cell number or LAN:
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Full mailing address:
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HEALTH Current medications taken with reason for taking and dosage instructions, along with current medical conditions (diabetes, depression, anxiety, heart disease, etc. ) :
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Please describe any vision, hearing, or other sensory problems (detail your history and treatment):
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Please describe development in early childhood (birth to age 6). Note any delays and interventions and the success of treatments:
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Please describe developmental and academic difficulties or delays that appeared in the elementary grades (1-8). Also describe interventions / treatments, and their success:
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Please describe any emotional, behavioral, and social problems and how they impacted the student across environments (home, school, socially). Also include details on the age of onset, treatment, and results:
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Please describe academic difficulties that appeared in the high school grades (9-12), interventions, and the success of interventions:
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Please describe any problems that appeared during the college or adult years (health, economic, social, emotional, etc.), interventions, and the success of those interventions:
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Please describe the reasons that you are seeking diagnostic testing, and what you hope the testing will accomplish:
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FAMILY HISTORY Do you have family members with learning disabilities or other disorders that impair personal success? If yes, please elaborate:
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Please describe your talents, strengths, and hobbies:
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Please describe your weaknesses:
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Please describe your goals for the immediate future. Include the name and location of schools, enrolled / future classes, majors and programs:
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Please describe your current occupation (student, job, community service, etc.):
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