Psychological Testing Intake (Updated 2024)
Child's Name
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DOB
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Month
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Day
Year
Date
Todays Date
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Month
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Day
Year
Date
PRESENTING PROBLEMS
Please list the questions you have and/or briefly describe the current difficulties for which you are seeking help:
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How long has this problem been a concern?
What age was the child when the problem was first noticed?
Why do you think the problem is happening?
What seems to help the problem?
What seems to make the problem worse?
Has the child received evaluation or treatment for the current problem or similar problem?
Yes
No
If yes, when and with whom?
Is your child currently under the care of a psychiatrist?
Yes
No
If yes, please explain:
MEDICATION
Has your child had any changes in Medications since you initially completed the Medical History and Demographic Packet with PAT when you initially became a New Patient?
Yes
No
Medication #1
Dosage #1
Frequency #1
Reason #1
Medication #2
Dosage #2
Frequency #2
Reason #2
Medication #3
Dosage #3
Frequency #3
Reason #3
Medication #4
Dosage #4
Frequency #4
Reason #4
BIRTH AND DEVELOPMENTAL HISTORY
Please list any birth defects:
Please rate your child on the following behaviors: Check 1 if the behavior on the left was present the majority of the time. Check 5 if the behavior on the right was present the majority of the time. Stages in between are represented by 2, 3, and 4.
Rows
1
2
3
4
5
Quiet and content -> colicky and irritable
Very easy to feed -> daily feeding problems
Slept well -> frequent sleeping problems
Usually relaxed -> often restless
Underactive -> overactive
Easily calmed down -> tantrums/headbanging
Cautious and careful -> accident prone/daredevil
Coordinated -> uncoordinated
Enjoyed eye contact -> avoided eye contact
Liked people -> disliked contact with people
Easily calmed down -> tantrums/headbanging
tantrums
headbanging
Cautious and careful -> accident prone/daredevil
accident prone
daredevil
Other problems or concerns regarding infancy or early childhood development:
EDUCATIONAL HISTORY
If your child has an IEP, what is the disability category that your child is served under?
Are there concerns regarding your child’s academic abilities?
Yes
No
If yes, please explain:
Does the child receive pull out services to help support academics?
Yes
No
If yes, please explain:
Does the child engage in maladaptive behavior at school?
Yes
No
If yes, please explain:
Has your child’s teacher reached out with any concerns about your child?
Yes
No
If yes, please explain:
SOCIAL AND BEHAVIORAL CHECKLIST
Place a check next to any behavior or problem that your child currently exhibits:
Has difficulty with speech
Has difficulty with hearing
Has difficulty with language
Has difficulty with vision
Has difficulty with coordination
Prefers to be alone
Has difficulty with change/transitioning
Does not get along well with brothers and sisters
Is aggressive
Is shy or timid
Is more interested in things (objects than in people)
Lies
Steals
Hoards
Special skills
Uncertain of new situations
Difficulty with peer relationships
Fearful
Avoidance/fear related to school/community birthday parties
Overly cautious
Has frequent tantrums
Has frequent nightmares
Has trouble sleeping
Rocks back and forth
Walks on toes
Bangs head
Problems with eating
Is stubborn
Engages in behavior that could be dangerous to self or others
Has special fears
Has trouble making eye contact
Bites nails
Sucks thumb
Wets bed
Is much too active
Has staring spells
Is impulsive
Is slow to learn
Gives up easily
Has toileting problems
Routines, compulsions, obsessions
Other
Special skills (describe):
Engages in behavior that could be dangerous to self or others (describe)
Has special fears (describe)
Has toileting problems (describe)
Routines, compulsions, obsessions (describe)
FAMILY MEDICAL AND MENTAL HEALTH HISTORY
Place a check next to any illness or condition that any member of the family has had.
Alcoholism
Cancer
Diabetes
Heart Trouble
Epilepsy
Intellectual Disability
School Difficulties
Language Difficulties
ADHD
Autism
Other Mental Health Condition
Hearing Impairment
Autism Spectrum Disorder
Obsessive Compulsive Disorder
Down Syndrome
Fragile X Syndrome
Anxiety Disorder
Depression
Bipolar Disorder
Suicide Attempt
Other
Alcoholism Relationship to Child
Cancer Relationship to Child
Diabetes Relationship to Child
Heart Trouble Relationship to Child
Epilepsy Relationship to Child
Intellectual Disability Relationship to Child
School Difficulties Relationship to Child
Language Difficulties Relationship to Child
ADHD Relationship to Child
Autism Relationship to Child
Other Mental Health Condition Relationship to Child
Hearing Impairment Relationship to Child
Autism Spectrum Disorder Relationship to Child
Obsessive Compulsive Disorder Relationship to Child
Down Syndrome Relationship to Child
Fragile X Syndrome Relationship to Child
Anxiety Disorder Relationship to Child
Depression Relationship to Child
Bipolar Disorder Relationship to Child
Suicide Attempt Relationship to Child
BEHAVIORAL AND OTHER INFORMATION
What are your child’s strengths?
What are your child’s favorite activities?
What are your child’s least favorite activities?
Has your child ever been in trouble with the law?
Yes
No
If yes, please describe briefly:
What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to each technique that you use:
Ignoring problem behavior
Scold child
Spank child
Threaten child
Reason with child
Redirect child’s interest
Tell child to sit on chair
Send child to his or her room
Take away some kind of activity
Other
Is there any other information that you think would help me work with your child or your family?
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