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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EARLY HISTORY:

You were born: [ ] On Time [ ] Prematurely [ ] LateYour weight at birth: ______ pounds _______ ounces

Were there any problems associated with your birth (e.g., oxygen deprivation, unusual birth position, etc.) or the period immediately afterward (e.g., need for oxygen, special equipment used, convulsions, illnesses, etc.)? Yes/No

If yes, please describe:

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Check any and all that applied to your mother while she was pregnant with you:[ ] Accident [ ] Psychological Problems[ ] Alcohol Use [ ] Drug Use (marijuana, speed, cocaine, LSD, etc.)[ ] Cigarette Smoking [ ] Poor Nutrition[ ] Illness (toxemia, diabetes, high blood pressure, infection, RH incompatibility, etc.)[ ] Other Problems: ________________________________________________________

List all the medications (prescribed or over the counter) your mother took while pregnant:

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If adopted, where from and at what age?:

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If adopted, what is known about the hereditary illnesses of your biological parents?:

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Rate your developmental progress as it has been reported to you by checking one description for each area:

Early Average LateWalking [ ] [ ] [ ]

Language [ ] [ ] [ ]Toilet Training [ ] [ ] [ ]Overall Development [ ] [ ] [ ]

As a child, did you have any of these conditions (Check all that apply):[ ] Attention Problems [ ] Head Injury[ ] Muscle Tightness or Weakness [ ] Clumsiness[ ] Hearing Problems [ ] Speech Problems[ ] Frequent Ear Infections [ ] Learning Disability[ ] Other Problems: ________________________________________________________

Were you ever tested for developmental disabilities (e.g., specific learningdisabilities, autism, etc.)? Yes/No

MEDICAL HISTORY:Check any and all the conditions that have been diagnosed during your life. Add any helpful details below (e.g. age at diagnosis, treatment provided) if the condition was serious.[ ] Allergies [ ] Lung (Respiratory) Disease[ ] Asthma [ ] Measles[ ] Brain Infection or Disease [ ] Meningitis[ ] Cancer/ Chemotherapy [ ] Oxygen Deprivation[ ] Cerebral Palsy [ ] Pneumonia[ ] Chicken Pox [ ] Poisoning[ ] Colds (excessive) [ ] Polio[ ] Diabetes [ ] Rheumatic Fever[ ] Encephalitis [ ] Scarlet Fever[ ] Fevers (104 F or higher) [ ] Tuberculosis[ ] Heart Disease/ Problems [ ] Venereal Disease[ ] Kidney Problems/ Disease [ ] Whooping Cough[ ] AIDS, ARC, or HIV + [ ] Liver Disease[ ] Arterioscleroses (Artery Disease) [ ] Malnutrition[ ] Arthritis [ ] Parkinson’s Disease[ ] Blood Disorder [ ] Multiple Sclerosis[ ] Epilepsy [ ] Psychiatric Problems[ ] Hazardous Substance Exposure [ ] Pulmonary Problems[ ] Huntington’s Disease [ ] Radiation Exposure/Therapy[ ] Hypertension [ ] Senility (Dementia)[ ] Stroke or TIA [ ] Thyroid Disease[ ] Other Disease/ Disability: ________________________________________________

Details: _________________________________________________________________________________________________

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Have you ever had surgery? If so, when and for what condition?:

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Any illnesses/incidents requiring hospitalization? Yes/NoIf yes, please explain: _________________________________________________________________________________________________

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Have you ever suffered a serious injury to your head? Yes/NoIf yes, describe:

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List any medications you are is currently taking or have taken for extended periods (give dates and dosage level, if possible):

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With which hand do you write? ______________________________________

Which language(s) are you fluent in? __________________________________

Do you have any vision problems? ___________________________________

Please list date of last vision test: ____________________________________

Do you have any hearing problems? _________________________________

Please list date of last hearing test:______________________________________

Name of Primary Care Physician: ___________________________________________________

Phone Number: ___________________________

Name of Psychotherapist (if Applicable):

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Phone Number: ___________________________

Name of Psychiatrist (if Applicable): ______________________________________________________

Phone Number :_____________________________

(Please list information for additional Physicians you see regularly on the back of this page.) Have you been in therapy before? If so, dcwhen, with whom, and did you feel that your goals were met? _____________________________________________________

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FAMILY HISTORY:

Mother’s occupation: ____________________________________________________________

Mother’s level of education: ______________________________________________________

Does/ did your mother have a known or suspected learning disability? [ ] Yes [ ] No

If Yes, please describe: __________________________________________________________

Briefly describe your mother’s health history:

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If deceased, please list cause of death and your age at the time of passing.

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Father:

Occupation: ____________________________________________________________

Level of education: ______________________________________________________

Does/ did your father have a known or suspected learning disability? [ ] Yes [ ] No

If Yes, please describe: __________________________________________________________

Briefly describe your father’s health history:

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If deceased, please list cause of death and your age at the time of passing.

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Siblings/Other Family:

Name Age Relation to you Mental/Health Issues

1. ____________ ______ _______________ __________________________________________________

2. ____________ ______ _______________ ___________________________________________________

3. ____________ ______ _______________ __________________________________________________

4. ____________ ______ _______________ __________________________________________________

Is there a history in your immediate or 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 __________________________

PSYCHOLOGICAL AND SOCIAL HISTORY:Current marital status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] WidowYears married to current spouse: ___________________________________________________

Number of times married: ________________________________________________________

Spouse’s occupation: ____________________________________________________________

Not married, but living with someone: [ ] Yes [ ] No If Yes, His/ Her age: ____________

His/ Her occupation: ____________________________________________________________Do you have children: [ ] Yes [ ] No

If Yes, please list child(ren’s) name(s), age(s), and sex:

Do you children have any health problems or special needs?

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Please rate your level of parenting stress (1 = very low, 10 = extremely high):

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With whom are you now living? (list)

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Describe any organizations, volunteering, hobbies, reading interests, or other leisure-timeactivities in which you engage in now or formerly?

Have you ever 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: ________________________________________________________________________

Have you been evaluated in the past? Yes/NoIf Yes, please list the following information on the previous evaluation(s): By Whom Type When 1. ______________________ ____________________ _______________

2. ______________________ ____________________ _______________

3. ______________________ ____________________ _______________

4. ______________________ ____________________ _______________

If yes, what were their general findings and recommendations?

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LEGAL:

Have you ever been convicted of a crime, or plead guilty to a crime? [ ] Yes [ ] NoIf Yes, please explain:

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Have you ever been incarcerated or on probation? [ ] Yes [ ] NoIf Yes, please explain:

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EDUCATIONAL HISTORY:Number of years of formal education completed: ______________________________________

Did you receive a: [ ] Diploma [ ] G.E.D. [ ] Neither

If diploma, please indicate degree (e.g., R.S., H.S., B.A., M.A., J.D., M.D., Ph.D.): __________

Where did you attend school (i.e., USA, Mexico, etc.)? ________________________________

How would you describe your usual performance as a student?[ ] A & B [ ] B & C [ ] C & D [ ] D & F

Please provide any additional helpful comments about your academic performance:

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What was your best subject(s): ______________________________ Grade(s): _______ What was your weakest subject(s): ___________________________ Grade(s): _______

Were you ever held back to repeat a grade? [ ] Yes [ ] No

Were you ever in any special class(es) or received special education services? Yes/NoIf Yes, what grade? __________________ or age? _____________________________

If college work done, what University? _______________________________________

What was your major? __________________________________________________

OCCUPATIONAL HISTORY:Are you currently employed? Yes/No

If No, are you on medical leave? Yes/No

Current (or most recent) job title: ________________________________________

How long had you been on this job? _______________________________________

Please give a brief description of your responsibilities:

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Please list all of the types of jobs you have had in the past and any problems there:

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Have you been in the military? Yes/NoIf Yes, please give branch, any disability rating, combat exposure, rank/ duties:_________________________________________________________________________________________________

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What was your favorite job? ___________________________________________

Have you ever filed a workers compensation claim? Yes/No

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SUBSTANCE USE HISTORY:Alcohol:

I drink alcohol: [ ] rarely or never [ ] 1 - 2 days per week[ ] 3 - 5 days per week [ ] daily[ ] I used to drink but stopped on (date): _______________________

Age when I first started drinking: _____________________________

Usual number of drinks I have at a time: ______________________________

My last drink was: [ ] less than 24 hrs ago [ ] 24 to 48 hrs ago [ ] over 48 hrs ago

Please list other substances used, prescription or over the counter medications used

recreationally, the frequency you have used them, and the date if you stopped:

Other addictive tendencies (compulsive shopping, gambling, sex, etc?):

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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 (sequencing 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 I read______ Difficulty spelling______ Difficulty following directions

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

Memory:______Forgetting where I leave things (e.g., keys, gloves, etc.)

______Forgetting names______Forgetting what I should be doing______Problems finding my way around places I have been to before______Forgetting where I am or where I am going______Not aware of time (i.e., time of day, season, year)______Forgetting time of day______Forgetting events that happened quite recently (e.g., my last meal)______Forgetting events that happened long ago (months or years)______Need someone to give me a hint so I can remember things______Relying more and more on notes to remember things______Forgetting the order of things (e.g., when cooking, etc.)______Forgetting facts, but I can remember how to do things______Forgetting how to do things, but I can remember facts______Forgetting faces of people I know (when they are not present)______Frequently forgetting appointments/meetings

Motor/Coordination:______Difficulty doing things I should automatically be able to do (e.g.,

brushing teeth, combing hair, etc.)______Problems drawing or copying______Difficulty dressing______Decline in my musical abilities______My 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, bad 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 my body seem as if they do not belong to me (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 my ears or hearing strange sounds (Left, Right, Both Ears)______Unaware of things on one side of my 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)______Much more emotional (e.g., cry more easily)______Loss of interest______Change in attitudes______Doing things automatically (without awareness)______Less inhibited (do things I would not do before)______Difficulty being spontaneous______Change in eating habits______Change in interest in sex

Social:

______Interpersonal problems______Marital problems______Tension with your parents

______Tension with your children______Tension with your boss______Tension with your co-workers______Trouble controlling temper______Social anxiety______Introversion______Isolation______Difficulty reading social cues______Easily irritated by others______Wish I had more friends______Wish I had more confidence

Please provide us with any other information on the psychological history that you feel would be helpful to us:

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Thank you for taking the time to complete this