Child Intake Questionnaire - NeuroPsych Doctor

Child Neuropsychology Intake Form (1)

"*" indicates required fields

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I. Identifying Information

Name of Person Completing this form

Child First Name*

Child Last Name*

Date of Birth*

Age

Gender

Current Grade

Current school

Past school (optional) #1

Past school (optional) #2

Past school (optional) #3

Primary Language(s) spoken at home

What is your child's current language ability?

non-verbal communication

early vocalizations and gestures

single words and simple combinations

phrases and developing sentences

expanded sentences and conversational speech

fluent, age-appropriate language

Is your child more fluent in another language than English in any area?

Consider speaking, reading, and/or writing.

Yes

If yes/unsure: What language is your child more fluent in?

In which areas is your child stronger in that language? (select all that apply)

Speaking

Understanding

Reading (Decoding)

Reading (Comprehension)

Writing (Basic)

Writing (Expressing thoughts)

Briefly describe what this looks like (examples of strengths in that language vs. English)

For example: speaks fluently at home but struggles in English at school; reads better in another language; writes more clearly in another language.

Handedness

Right

Left

Mixed

Not yet established

Parent/Guardian #1 Name

Parent/Guardian #1 Relationship

Biological parent

Step-parent

Adoptive parent

Foster parent

Grandparent

Other

Parent/Guardian #1 Phone

Parent/Guardian #1 Email*

Parent/Guardian #2 Name

Parent/Guardian #2 Relationship

Biological parent

Step-parent

Adoptive parent

Foster parent

Grandparent

Other

Parent/Guardian #2 Phone

Parent/Guardian #2 Email

Who referred you?

II. Referral Concerns & History

Common reasons for evaluation (select all that apply)

Other reason for evaluation (please describe)

Attention / distractibility – specific concerns (select all that apply)

Easily distracted

Difficulty sustaining attention

Trouble finishing tasks

Difficulty following directions

Needs frequent reminders

Difficulty attending during group activities (circle time, story time)

Other / unsure

Attention / distractibility – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Hyperactivity / impulsivity – specific concerns (select all that apply)

Fidgets or squirms

Difficulty staying seated

Acts without thinking

Interrupts others

Difficulty waiting turn

Other / unsure

Hyperactivity / impulsivity – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Executive functioning – specific concerns (select all that apply)

Difficulty organizing materials

Trouble starting tasks

Difficulty completing multi-step tasks

Loses belongings

Difficulty with transitions

Other / unsure

Executive functioning – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Social concerns – specific concerns (select all that apply)

Social concerns – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Learning / academic concerns – specific concerns (select all that apply)

Skills below age or grade expectations

Uneven academic skills

Slow progress despite practice

Academic frustration or avoidance

Teacher has expressed concerns

Other / unsure

Learning / academic concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Reading concerns – specific concerns (select all that apply)

Difficulty recognizing letters

Difficulty naming letters

Difficulty learning letter sounds

Difficulty blending sounds to read simple words

Slow or effortful reading

Poor reading accuracy

Difficulty understanding what is read

Avoids reading activities

Other / unsure

Reading concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Writing / spelling concerns – specific concerns (select all that apply)

Difficulty forming letters

Difficulty writing own name

Writes letters backwards

Poor handwriting

Difficulty spelling words

Writing is slow or effortful

Avoids drawing or writing activities

Other / unsure

Writing / spelling concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Math concerns – specific concerns (select all that apply)

Difficulty recognizing numbers

Difficulty counting objects

Difficulty understanding “how many”

Difficulty learning basic math facts

Difficulty with word problems

Math anxiety or avoidance

Other / unsure

Math concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Language concerns – specific concerns (select all that apply)

Difficulty understanding directions

Limited vocabulary for age

Difficulty expressing thoughts clearly

Trouble answering questions

Other / unsure

Language concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Autism / social communication concerns – specific concerns (select all that apply)

Limited eye contact

Difficulty with peer interactions

Limited pretend play

Difficulty understanding social cues

Repetitive behaviors or interests

Difficulty with transitions

Sensory sensitivities

Did not smile socially before 6 months

Other / unsure

Autism / social communication concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Behavior concerns – specific concerns (select all that apply)

Frequent meltdowns

Aggression

Defiance or noncompliance

Emotional outbursts

Other / unsure

Behavior concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Anxiety / worries / fears – specific concerns (select all that apply)

Excessive worry

Separation anxiety

School anxiety

Physical complaints related to stress

Other / unsure

Anxiety / worries / fears – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Depression / mood concerns – specific concerns (select all that apply)

Persistent sadness

Irritability

Low motivation

Negative self-talk

Other / unsure

Depression / mood concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Memory concerns – specific concerns (select all that apply)

Difficulty remembering instructions

Forgets learned information

Needs frequent repetition

Other / unsure

Memory concerns – specific concerns (select all that apply) – More information

Optional: add examples, settings (home/school), and anything else you want the clinician to know.

Primary reasons for evaluation / chief concerns

Describe the primary reasons for seeking an evaluation.

When did these concerns begin and how have they changed over time?

What has been done to address these concerns so far?

Has your child ever been diagnosed (in the past or currently) with any disorder or condition?

Yes

If yes or unsure: Please select any diagnoses/conditions that apply (select all that apply)

Approximate age when diagnosed: ADHD (Attention-Deficit/Hyperactivity Disorder)

(If unknown, leave blank.)

Approximate age when diagnosed: Autism Spectrum Disorder (ASD)

(If unknown, leave blank.)

Approximate age when diagnosed: Social (Pragmatic) Communication Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Language Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Speech Sound Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Specific Learning Disorder – Reading (Dyslexia)

(If unknown, leave blank.)

Approximate age when diagnosed: Specific Learning Disorder – Written Expression (Dysgraphia)

(If unknown, leave blank.)

Approximate age when diagnosed: Specific Learning Disorder – Mathematics (Dyscalculia)

(If unknown, leave blank.)

Approximate age when diagnosed: Intellectual Developmental Disorder (Intellectual Disability)

(If unknown, leave blank.)

Approximate age when diagnosed: Global Developmental Delay

(If unknown, leave blank.)

Approximate age when diagnosed: Developmental Coordination Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Anxiety Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Obsessive-Compulsive Disorder (OCD)

(If unknown, leave blank.)

Approximate age when diagnosed: Depressive Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Bipolar Disorder

(If unknown, leave blank.)

Approximate age when diagnosed: Disruptive Mood Dysregulation Disorder (DMDD)

(If unknown, leave blank.)

Approximate age when diagnosed: Oppositional Defiant Disorder (ODD)

(If unknown, leave blank.)

Approximate age when diagnosed: Trauma- and Stressor-Related Disorder (e.g., PTSD)

(If unknown, leave blank.)

Approximate age when diagnosed: Tic Disorder / Tourette’s Disorder

(If unknown, leave blank.)

If known, please provide the year (or date) of diagnosis for any selected diagnoses

You can list multiple (e.g., ADHD 2021; ASD 2023).

Please list any additional diagnoses/conditions not listed above, and any details you’d like us to know

Prior psychological or neuropsychological evaluations?

Yes

Upload prior evaluation report (if available)

Please upload a copy of any prior psychological/neuropsychological evaluation report.

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB.

If yes: Date of prior evaluation

If yes: Reason and brief summary of prior evaluation (if known)

Any traumatic or significant life events that may have affected your child?

Yes

Unsure

If Yes/Unsure: please describe (optional)*

Include approximate timing and how it may have affected your child.

Any suicidal or self-harm thoughts/behaviors?

Yes

If you have adaptive skills / daily living concerns, please select any that apply:

Dressing independently

Toileting / accidents

Hygiene (brushing teeth, bathing)

Feeding (needs help, limited independence)

Difficulty with routines

Poor safety awareness

Limited independence for age

Other / unsure

Please describe (details, examples, settings where this occurs):

If you have sleep concerns, please select any that apply:

Difficulty falling asleep

Difficulty staying asleep

Frequent night wakings

Early morning awakenings

Nightmares or night terrors

Co-sleeping concerns

Daytime sleepiness

Other / unsure

Please describe (details, examples, settings where this occurs):

If you have eating / feeding concerns, please select any that apply:

Please describe (details, examples, settings where this occurs):

If yes: please describe (and contact emergency services if there is immediate risk).

Cognitive Behavioral Therapy (CBT) – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Cognitive Behavioral Therapy (CBT) – Setting/location

School / clinic / home / telehealth (optional).

Play Therapy – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Play Therapy – Setting/location

School / clinic / home / telehealth (optional).

Social Skills Group – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Social Skills Group – Setting/location

School / clinic / home / telehealth (optional).

Executive Function Coaching – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Executive Function Coaching – Setting/location

School / clinic / home / telehealth (optional).

Parent Training / Parent Coaching – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Parent Training / Parent Coaching – Setting/location

School / clinic / home / telehealth (optional).

Psychological Therapy / Counseling – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Psychological Therapy / Counseling – Setting/location

School / clinic / home / telehealth (optional).

Psychiatric Medication Management – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Psychiatric Medication Management – Setting/location

School / clinic / home / telehealth (optional).

Feeding Therapy – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Feeding Therapy – Setting/location

School / clinic / home / telehealth (optional).

Vision Therapy – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Vision Therapy – Setting/location

School / clinic / home / telehealth (optional).

Hearing / Auditory Therapy – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Hearing / Auditory Therapy – Setting/location

School / clinic / home / telehealth (optional).

Other (explain below) – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Other (explain below) – Setting/location

School / clinic / home / telehealth (optional).

III. Services and Interventions

IEP?

Yes

Don’t know

If IEP = Yes: classification (select one)

Other Health Impairment (OHI)

Specific Learning Disability (SLD)

Autism

Speech or Language Impairment

Emotional Disturbance

Intellectual Disability

Traumatic Brain Injury

Other / Unknown

504 Plan?

Yes

Don’t know

Upload IEP and/or 504 Plan (optional)

Please upload the most recent IEP and/or 504 Plan if available.

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB.

Classroom type / placement (select one)

General education

Integrated co-teaching (ICT) / inclusion

Self-contained (12:1 or similar)

Self-contained (12:1:1 / 8:1:2 or similar)

Specialized school / non-public placement

Home instruction

Other

If 'Other', please specify classroom type

Does your child receive special education services?

Yes

Unsure

Services and interventions received (select all that apply)

Include school-based and private services.

Speech-language therapy — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Occupational Therapy (OT) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Physical Therapy (PT) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Counseling (school-based) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Social work services — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

SETSS / Special education teacher support — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Resource room — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

ICT / co-teaching support — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

1:1 paraprofessional — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Behavior intervention plan (BIP) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Adaptive Physical Education — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Applied Behavior Analysis (ABA) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Early Intervention (EI) services — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Special Education / Resource Room — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Academic Tutoring — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Behavioral Therapy — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Cognitive Behavioral Therapy (CBT) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Play Therapy — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Social Skills Group — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Executive Function Coaching — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Parent Training / Parent Coaching — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Psychological Therapy / Counseling — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Psychiatric Medication Management — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Feeding Therapy — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Vision Therapy — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Hearing / Auditory Therapy — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Other (explain below) — details

Is this service part of an IEP or 504 Plan?

Yes

Unsure

Where is this service provided?

School-based

Private / outside school

Both

Unsure

Is this service currently being provided?

Yes

Unsure

When did this service start? (approximate month/year)

If ended: when did this service end? (approximate month/year)

Does your child receive classroom/testing accommodations?

Yes

Unsure

Common accommodations (select all that apply)

Extra time on tests

Quiet room / small group testing

Class outline/notes provided

Modified tests

Pre-teaching/tutor/SETSS

Tests read aloud

Verbal responses allowed

Other (explain below)

Has your child ever repeated or skipped a grade?

Repeated a grade

Skipped a grade

None

N/A

If repeated or skipped: please describe (which grade and why, if known)

For example: speaks fluently at home but struggles in English at school; reads better in another language; writes more clearly in another language.

IV. Pregnancy, Birth, and Early Development

Was the pregnancy planned?

Yes

Unknown

Pregnancy exposures (select all that apply)

Tobacco

Alcohol

Caffeine

Other drugs/medications

Any pregnancy complications?

Yes

Unknown

If Yes: pregnancy complications (select all that apply)

Pregnancy complications – Other/details

Duration of pregnancy (weeks)

Birth Weight (pounds and ounces)

Delivery type

Vaginal

C-section

Unknown

If C-section: reason (if known)

Birth complications or special care after birth (NICU)?

Yes

Unknown

If Yes: birth complications / special care (select all that apply)

Birth complications – Other/details

If yes: describe complications/special care, duration, and reason

Infant temperament in the first two years (select all that apply)

Select any that fit. If unsure, leave blank.

Infant temperament – Other (please describe)

Smiled socially before 6 months of age?

Yes

Unsure

Pointed to show interest (e.g., pointing at something to share)?

Yes

Unsure

Followed others’ pointing (looked where you pointed)?

Yes

Unsure

Any developmental delays or regressions?

Yes

V. Developmental History

If Yes: common developmental concerns (select all that apply)

Developmental concerns – Other/details

Developmental concerns by domain (select all that apply)

After selecting a domain, more specific items will appear.

Language / Communication

Motor (gross/fine)

Sensory processing

Social communication / Play

Attention / Executive functioning

Emotional / Behavioral regulation

Adaptive / Daily living skills

Learning / Academics

Other (describe below)

Language / Communication: specific concerns (select all that apply)

Delayed speech or language development

Difficulty understanding language

Limited vocabulary for age

Speech clarity/articulation problems

Pragmatic/social language difficulties

Motor (gross/fine): specific concerns (select all that apply)

Delayed motor milestones (sitting/crawling/walking)

Poor fine motor skills (writing/buttoning/scissors)

Poor gross motor coordination or clumsiness

Poor handwriting / graphomotor difficulties

Sensory processing: specific concerns (select all that apply)

Sensitive to sound

Sensitive to light

Sensitive to touch/textures/clothing

Seeks sensory input (movement/crashing/chewing)

Picky eater related to textures

Social communication / Play: specific concerns (select all that apply)

Limited eye contact or social engagement

Difficulty with peer interactions

Limited pretend or imaginative play

Repetitive behaviors or restricted interests

Difficulty with transitions or changes in routine

Did not smile before 6 months old

Attention / Executive functioning: specific concerns (select all that apply)

Inattention/distractibility

Hyperactivity

Impulsivity

Disorganization / losing items

Difficulty planning/initiating tasks

Forgetfulness

Emotional / Behavioral regulation: specific concerns (select all that apply)

Emotional regulation difficulties (meltdowns/mood swings)

Anxiety/excessive fears

Irritability / frequent anger

Oppositional behavior / noncompliance

Aggression (verbal/physical)

Adaptive / Daily living skills: specific concerns (select all that apply)

Delayed self-care (dressing, hygiene)

Toileting concerns

Sleep problems

Feeding/eating concerns

Safety awareness concerns

Learning / Academics: specific concerns (select all that apply)

Learning difficulties / slow academic progress

Reading difficulties

Writing/spelling difficulties

Math difficulties

School avoidance / refusal

Developmental concerns – Other (please describe)

Speech-Language Therapy – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Speech-Language Therapy – Setting/location

School / clinic / home / telehealth (optional).

Occupational Therapy (OT) – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Occupational Therapy (OT) – Setting/location

School / clinic / home / telehealth (optional).

Physical Therapy (PT) – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Physical Therapy (PT) – Setting/location

School / clinic / home / telehealth (optional).

Applied Behavior Analysis (ABA) – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Applied Behavior Analysis (ABA) – Setting/location

School / clinic / home / telehealth (optional).

Early Intervention (EI) services – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Early Intervention (EI) services – Setting/location

School / clinic / home / telehealth (optional).

Special Education / Resource Room – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Special Education / Resource Room – Setting/location

School / clinic / home / telehealth (optional).

Academic Tutoring – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Academic Tutoring – Setting/location

School / clinic / home / telehealth (optional).

Behavioral Therapy – Approximate dates received

Example: 2019–2021, or age 3–5, or 'ongoing'.

Behavioral Therapy – Setting/location

School / clinic / home / telehealth (optional).

VI. Medical History

Does your child currently take any medication?

Yes

Medication type(s) (select all that apply)

Stimulant (e.g., methylphenidate/amphetamine)

Non-stimulant ADHD medication (e.g., atomoxetine/guanfacine/clonidine)

SSRI / antidepressant

Anti-anxiety medication

Mood stabilizer

Antipsychotic

Sleep medication

Other

Medication details (name, dose, reason, benefits/side effects)

Medical history (select all that apply)

Surgeries

Seizures

Frequent ear infections

Headaches

Head injury

Allergies

Hospitalizations

Other (explain below)

Head injury / significant falls – details (optional)

If applicable: age at injury, loss of consciousness, medical evaluation, and any ongoing symptoms.

Headaches – details (optional)

If applicable: frequency, severity, and any known triggers.

Details for medical history items selected (what, when, outcome)

VII. Family & Living Situation

Religious affiliation

If Other, please specify religious affiliation

Level of religiosity / religious practice

Are parents living together?

Yes

If no: custody/living arrangement (who does the child live with most of the time?)

Siblings

Add one row per sibling. If none, leave blank.

Family history (select all that apply)

Select any conditions present in the family

Who in the family has ADHD? (e.g., mother, father, sibling, grandparent)*

Who in the family has Learning disability? (e.g., mother, father, sibling, grandparent)*

Who in the family has Developmental delay? (e.g., mother, father, sibling, grandparent)*

Who in the family has Autism spectrum disorder? (e.g., mother, father, sibling, grandparent)*

Who in the family has Speech/language disorder? (e.g., mother, father, sibling, grandparent)*

Who in the family has Anxiety? (e.g., mother, father, sibling, grandparent)*

Who in the family has Depression? (e.g., mother, father, sibling, grandparent)*

Who in the family has OCD? (e.g., mother, father, sibling, grandparent)*

Who in the family has Bipolar disorder? (e.g., mother, father, sibling, grandparent)*

Who in the family has Schizophrenia/psychosis? (e.g., mother, father, sibling, grandparent)*

Who in the family has Intellectual disability? (e.g., mother, father, sibling, grandparent)*

Who in the family has Substance use (alcohol/drugs)? (e.g., mother, father, sibling, grandparent)*

Who in the family has Other? (e.g., mother, father, sibling, grandparent)*

Current family stressors (past 12 months) (select all that apply)

Death or serious illness in the family

Parental separation/divorce

Job loss or financial stress

Move or housing changes

Other (describe below)

Current family stressors – Other/details

IX. School Functioning

Is your child currently in general education or special education?

General education

Special education

Combination / integrated

Not sure

Speech-language therapy – format

Individual

Group

Both

N/A

Speech-language therapy – frequency/duration*

Occupational Therapy (OT) – format

Individual

Group

Both

N/A

Occupational Therapy (OT) – frequency/duration*

Physical Therapy (PT) – format

Individual

Group

Both

N/A

Physical Therapy (PT) – frequency/duration*

Counseling (school-based) – format

Individual

Group

Both

N/A

Counseling (school-based) – frequency/duration*

Social work services – format

Individual

Group

Both

N/A

Social work services – frequency/duration*

SETSS / Special education teacher support – format

Individual

Group

Both

N/A

SETSS / Special education teacher support – frequency/duration*

Resource room – format

Individual

Group

Both

N/A

Resource room – frequency/duration*

ICT / co-teaching support – format

Individual

Group

Both

N/A

ICT / co-teaching support – frequency/duration*

1:1 paraprofessional – format

Individual

Group

Both

N/A

1:1 paraprofessional – frequency/duration*

Behavior intervention plan (BIP) – format

Individual

Group

Both

N/A

Behavior intervention plan (BIP) – frequency/duration*

Adaptive Physical Education – format

Individual

Group

Both

N/A

Adaptive Physical Education – frequency/duration*

Other special education service (please specify)*

Teacher concerns (select all that apply)

If you have teacher feedback, select the areas of concern.

Teacher concerns – Other (please describe)*

Homework independence

Independent

Independent with reminders

Needs supervision

X. Additional Strengths & Interests

Child’s strengths, talents, and interests (select all that apply)

Strengths – More information

Strengths – Other details

Extracurriculars / hobbies / activities (select all that apply)

Activities – More information

Activities – Other details

Anything else important to share?

Upload any other important documents (optional)

Examples: previous testing, school reports, progress notes, therapy summaries, report cards, relevant medical records.

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB.

XI. Teacher Information

Teacher/Provider Name

Please provide the name and contact information for a teacher or provider who can be contacted about your child.

Prefix Last Suffix

Relationship with the Child

Teacher Email

Teacher Phone

Additional documents (optional)

You may upload any additional records you would like the clinician to review (e.g., reports, notes, school records).

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB.

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Child Neuropsychology Intake Form (1)

I. Identifying Information

II. Referral Concerns & History

III. Services and Interventions

Speech-language therapy — details

Occupational Therapy (OT) — details

Physical Therapy (PT) — details

Counseling (school-based) — details

Social work services — details

SETSS / Special education teacher support — details

Resource room — details

ICT / co-teaching support — details

1:1 paraprofessional — details

Behavior intervention plan (BIP) — details

Adaptive Physical Education — details

Applied Behavior Analysis (ABA) — details

Early Intervention (EI) services — details

Special Education / Resource Room — details

Academic Tutoring — details

Behavioral Therapy — details

Cognitive Behavioral Therapy (CBT) — details

Play Therapy — details

Social Skills Group — details

Executive Function Coaching — details

Parent Training / Parent Coaching — details

Psychological Therapy / Counseling — details

Psychiatric Medication Management — details

Feeding Therapy — details

Vision Therapy — details

Hearing / Auditory Therapy — details

Other (explain below) — details

IV. Pregnancy, Birth, and Early Development

V. Developmental History

VI. Medical History

VII. Family & Living Situation

IX. School Functioning

X. Additional Strengths & Interests

XI. Teacher Information

Evaluation Types

More Info