Psychoeducational Intake Form
Please allow 30-45 minutes to complete the entire intake form. Please submit it once you have completed.
Child's Name
Date of Birth
Age
Current School Grade
Current School Enrollment
Name of Person Completing this Form
Please describe your current concerns about your child:
How long have you had these concerns?
Please list the names and relations of people who currently live with the child.
Name
Relationship to Child
Name
Relationship to Child
Name
Relationship to Child
Mother's Name
Phone
Email
Occupation
Address
Father's Name
Phone
Email
Occupation
Address
Developmental History
Any before or after birth problems?
Any problems during infancy or toddler years?
Was the child delayed in reaching any milestones? Walking, Talking, etc.
Any speech or language difficulties?
Any vision or heaing difficulties?
List all childhood illnesses, chronic ear infections, hospitalizations, medications, allergies, head trauma, important accidents and injuries, surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions:
Please list all current medications the child is taking:
Please list past medications child has taken:
Behavior
Please list any concerns you have about your child's behavior:
How does your child get along with peers?
How does your child get along with siblings?
Are there any stressful events occurring in the family that may be affecting your child?
To your knowledge, has your child ever been abused or neglected?
Is there anyone in the child's family that has ever had: Learning Difficulties, Attentional Problems, Emotional Difficulties , Diagnosed Disorder(s), Alcohol or Drug problems, Their own history of abuse?
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Any previous diagnoses for your child?
Please list any current intervention your child is receiving (Speech, OT, PT, psychotherapy):
Please list any past treatment for your child (Speech, OT, PT, psychotherapy):
Please list any past evaluations for your child (Speech, OT, PT, Psychological, Educational/School):
Does your child currently receive any special education services?
Does (did) your child have any problems learning letters/numbers?
Name of child’s pediatrician/primary care doctor. Name of practice.
Would you like a copy of any assessment results sent to the doctor?
Please tell us how you found out about School Success?
Any other information that you feel is important, or questions you would like answered through assessment:
Signature of Person Completing Form
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