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Adult Neuropsychology Intake Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

I. Identifying Information

Are you completing this form for yourself?
MM slash DD slash YYYY
Are you more fluent in a language other than English in any area?
Consider speaking, reading, and/or writing.
In which areas are you stronger in that language? (select all that apply)
For example: speaks fluently at home but struggles in English at work; reads better in another language; writes more clearly in another language.
Handedness

II. Education & Occupational History

Highest level of education completed
Current status (select all that apply)
Have you ever received accommodations (academic or workplace)?

III. Referral Information

What type of evaluation are you seeking? (select all that apply)

IV. Primary Concerns

Common reasons for evaluation (select all that apply)
Describe the primary reasons for seeking an evaluation.

V. Symptom-Specific Concerns

Attention / distractibility – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Hyperactivity / impulsivity – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Executive functioning – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Learning / academic – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Autism / social communication – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Anxiety / worries – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Depression / mood – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.
Memory – specific concerns (select all that apply)
Optional: add examples (work/school/home), and anything else you want the clinician to know.

VI. History & Course

Examples: therapy, medication, coaching, accommodations, self-strategies.

VII. Diagnostic & Medical History

Have you ever been diagnosed (in childhood or adulthood) with any psychological, neurodevelopmental, neurological, or medical condition?
If yes/unsure: Please select any diagnoses/conditions that apply (select all that apply)

VIII. Functional Impact & Goals

How do these difficulties affect your daily life? (select all that apply)
What are you hoping to gain from this evaluation? (select all that apply)

IX. Emergency / Collateral Contact

Is this person aware you are seeking an evaluation?
Evaluation Types
  • Academic Disability Evaluation
  • ADHD Evaluation
  • Autism Evaluation
  • Testing Accommodations Evaluation
  • Medical Disability Evaluation
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