CReATE Adult Intake Form

Please complete the following information so that we can better determine the type of evaluation needed. If you would prefer a paper copy of this Intake Form or you have any difficulties, please call our office at 828-231-3297

This form is comprised mainly of checklists, allowing you to scan and complete quickly. There is a section at the beginning to write about your overall concerns; each section thereafter allows for some description if needed. Please enter descriptive information only when you feel it will be helpful or relevant to your main concerns; it is unnecessary to provide a description in every box. You will have ample opportunity to provide more information directly to the psychologist over the course of the evaluation process.

The information submitted in this form is guaranteed to be kept confidential and secure.
Please wait for the confirmation page to appear once you submit your form.
 

Client Information

First Name: *
Last Name: *
Biological Sex:
Gender:
Birth Date: mm/dd/yyyy *
Hand Preference:
Address: *
Phone: *
Email: *  
Preferred Method of Contact:
Primary Language:
Secondary Language:
Emergency Contact (Name and Phone):
Financial Guarantor:


If you are completing the intake on behalf of the Client, please provide:

Your First and Last Name:
Relationship to client:
Your address (if applicable):
Your Phone Number (if applicable):
Your Email Address (if applicable):  
Preferred Method of Contact:
Do you have Health Care POA for the client?:

Referral Information:

Who referred you to CReATE or how did you hear about us?

Do you want us to have contact with your referral source?
If yes, Name and phone number of referral source:

Were you referred to a specific psychologist? Name:
Briefly describe the reason for referral, concerns, or a little about your (or the client’s) current difficulties:

What would you (or the client) like to learn from this evaluation?

How long have these concerns/difficulties been present (months, years, or age at which concerns/ difficulties began):

Were these concerns/difficulties the result of a known event/injury (e.g., brain injury, stroke, illness etc.)?
If Known Event, please check all that apply:
Please describe the event(s) including dates, if possible:

Areas of concern:
Check all that apply:
   

Is any legal action currently underway or pending?
If yes, please describe:

Type of Evaluation (check all that apply):

Description: (Optional)

Current Symptoms/Problems:

Check all that apply:

Memory
 

Attention

Processing Speed
 

Executive Functioning
 

Nonverbal / Visual-Spatial
 

Coordination / Motor Function

Speech / Language

Sensory / Perceptual

Physical

Mood

Thoughts

Behavior
 

Social

Adaptive behavior


Description for any items checked (Optional):

Substance Use:

  No Use Only Rarely Current Use Past Use Frequency Date of
Last Use
Unknown
Alcohol
Marijuana
Cocaine
Heroin
MDMA
(e.g. "Ecstasy")
Hallucinogenics
(e.g. LSD, “Acid”)
Prescription Pain
(Opiates)
Prescription Anxiolytic
(Xanax, Valium, etc.)
Other:

Substance use has contributed to:

Description (Optional):

Medical History:

Neurologic: Endocrine:
 
 
 
 
Cardiovascular: Ear, Nose, & Throat:
 
 
 
Genital-Urinary/Gastro-Intestinal: Muscular- Skeletal:
 
Mental Health (previously diagnosed): Oncology/Hematology:
  Other:
 
Neurodevelopmental (previously diagnosed): Genetic:
 
 
Acquired: Infections:
 

Description (Optional):
 
Which of the following scans/tests have previously been performed (please check all that apply):
Briefly summarize findings, if you can, as well as approximate date(s) of tests. If there are too many to summarize or you are unsure of results, please be sure to send records. Our fax number is (888) 224-5899.


Does the client have any food or drug allergies?
If yes, please list:
Is the client prescribed any medications or alternative medicines or supplements?
If yes, please list:
Medications/Supplements
  Past Use Current Use Dosage/Frequency Purpose
Description (Optional):


Name of Primary Care Physician (PCP) and Practice:
Approximate Date of Last Visit:
Were vision and hearing screenings normal?
If no, explain:

Treatment History:

 
Description (Optional):
Please list names of any current treatment providers (e.g. Ms. C, therapist; Dr. X, psychiatrist, etc.):

Assessment History

Give approximate dates of prior testing if applicable:

Family History: (please indicate if any family members have been diagnosed with the following:)

Age Related Diseases:





Mental Health:










Neurodevelopmental:





Description (Please indicate relatives diagnosed or other relevant info):

Birth History and Early Development:

Known Health Problems in Biological Mother during Pregnancy:
To the best of your knowledge, did your (or the client’s) biological mother smoke,
drink alcohol, or use drugs while pregnant with you (or the client)?

 
Birth History:
 
 
Approximate birth weight:
 
Known Health Problems in Infancy or Early Development:
 
 
Description (Optional):

Personal Information:

Client is living... Client is...
 
 
Client is... Client is...
 
 
Early Life Stressors:
Significant Stressors:
Loss:
 
Education
Description (Optional):

Strengths/Hobbies/Interests/Achievements/Positive Traits:

Optional / Young Adults:

If client is young adult and seeking services related to educational planning, please scan through the following list and check if any of the following difficulties during childhood or adolescence were evident, if known. Please check all that apply:
 
Reading













During middle school and high school years:


 
Math











During middle school and high school years:



 
Writing











During middle school and high school years:





Please take a moment to review your answers before submitting this form. Make sure all fields marked with a (*) are completed and the information you provide is as accurate as possible. Only press the submit button once. Be patient as occasionally it takes a moment to submit the form. The information submitted in this form is guaranteed to be kept confidential and secure.