Screening Intake Form

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Please fill out this form for each person in your family for whom you are interested in having evaluations done.

YYYY

Name of person completing form and relation to person being evaluated:

First and last name of person being evaluated:

Date of Birth:

YYYY

Age:

Gender *

Male

Female

Prefer not to say

Street or Mailing Address *

City and Zip Code: *

Phone Number (if for a minor, please provide the Guardian's phone number): *

Email Address (if for a minor, please provide the Guardian's email address): *

Why are you seeking evaluation at this time? (Please choose all that apply) *

For my own knowledge and peace of mind

For scholarship purposes

To develop an IEP or 504

An entity is requiring this (court, occupational, medical, etc.)

To apply for benefits

For compensatory strategy and assistance, if needed

Tutoring

Other:

Required

Is there something specifically for which you would like us to check? *

What are your concerns? *

Have you noticed behaviors, tendencies, or issues that concern you? *

When did you first begin to notice the areas of concern and in what capacity (if you can think of a specific moment, please provide any supporting details you may remember)? *

Is there a family history of any of the following? *

ADHD

ASD (Autism Spectrum Disorder, including previously recognized diagnoses like PDD-NOS or Asperger's)

BiPolar Disorder (Type 1 or 2)

Intellectual Disability or Developmental Delay

Learning Disabilities (specific or non)

CAPD (Central Auditory Processing Disorder)

Any Other Developmental Disorder (please specify if yes)

Behavioral Disorder other than above (please specify if yes)

Chromosomal Disorder (please specify if yes)

Sensory Processing Issues

Other:

Required

Does this person have any "odd", "unusual", or extreme behaviors? For example, do they have strong aversions to things the average person would not? Do they have rituals or routines that seem "over the top"? Are they more clumsy than their peers? Please mention any behaviors that you find noteable. *

Are you interested in testing for personal informational purposes or screening without a formal diagnosis?
*

Yes

If yes, please indicate the following:

Executive Functioning (adult)

Executive Functioning (child)

Scholastic Achievement (adult)

Scholastic Achievement (child)

Processing Ability Information (Processing examples are: attention, memory, emotion, sensory, perception, speed, and executive function)

Social &/OR Emotional Function

Reasoning Ability Information (Reasoning Ability relates to Cogitation, Intelligence, Critical Thinking, Logistics, Cause & Effect, Judgement)

Other:

Would you like to provide us with blanket consent to speak with, email, share information, and/or receive information with a person close to you or another clinician or provider? *

Yes

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