CReATE Child/Adolescent Intake Form

Please complete the following information so that we can better determine the type of evaluation needed. If 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 and family information; 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: Child/Adolescent*
Preferred Name:
Last Name: Child/Adolescent*
Biological Sex/Gender: *(please specify if different)
Birth Date: mm/dd/yyyy *
Current Grade: *
Current School: *
Hand Preference:
Primary Language:
Secondary Language:
Name of Person Completing this form:
Relation to child/adolescent:
Address: *
Phone: *
Email: *  
Preferred Method of Contact:
Second Parent Phone (optional):
Second Parent Email (optional):  
Emergency Contact (Name and Phone):

Referral Information:

Briefly describe the reason for referral, concerns, or a little about your child/adolescent's current difficulties:

What would you like to learn from this evaluation?

How long have these concerns/difficulties been present?

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:

Family Information:

Does your child/adolescent live with both parents?
If no, briefly describe custody and living arrangements:

Is the other parent aware that you are seeking an evaluation for your child?
If no, explanation:

Is any legal action currently underway in this family?
If yes, please explain:

Parent 1 Name and Occupation/Education (optional):
Parent 1 Relationship:
Parent 2 Name and Occupation/Education (optional):
Parent 2 Relationship:
Parent 3 Name and Occupation/Education (if applicable, optional):
Parent 3 Relationship:
Parent 4 Name and Occupation/Education (if applicable, optional):
Parent 4 Relationship:
Siblings (number of siblings, names, and ages):

Type of Evaluation:


Description: (Optional)

Areas of concern (check all that apply):






















Current Symptoms/Problems:

Check all that apply:

Attention

Processing Speed

Executive Functioning

Nonverbal / Visual-Spatial

Memory

Coordination / Motor Function

Speech / Language
 

Sensory / Perceptual

Physical
 

Mood

Thoughts
 

Behavior

Social
 

Adaptive behavior


Description for any items checked (Optional):



Were any of 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:

Birth History and Early Development:

Known Health Problems in Biological Mother during Pregnancy:
To the best of your knowledge, did the biological mother smoke,
drink alcohol, or use drugs while pregnant with this child?

 
Birth History:
 
 
Approximate birth weight:
 
Problems in Infancy or Early Development:

Description (Optional):

Educational History:

Name of preschool(s) and number of years attended:

Name of elementary school(s) and grades attended:

Name of middle school(s) and grades attended:

Name of high school(s) and grades attended:

Type of Classroom Setting:

Academic Concerns

Reading













During middle school and high school years:


 
Math











During middle school and high school years:


 
Writing











During middle school and high school years:



Medical History:

Name of Pediatrician or PCP and Practice:
Approximate Date of Last Visit:
Were vision and hearing screenings normal?
If no, please explain:

Are your child’s immunizations up to date?
If no, please explain:


Neurologic: Ear, Nose, and Throat:
















 
Cardiovascular:



Endocrine:


 
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.


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


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:)

Neurodevelopmental:








Mental Health:










Medical:




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

Psychosocial Stressors:




















Description (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):

Strengths/Hobbies/Interests/Achievements/Positive Traits:

Strengths and Positive Traits:

Hobbies and Interests:

Extracurricular Activities:

Academic or Nonacademic Achievements:



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.