Create Adult Form - Self-Completed (Ages 18+)

Please complete the following information so that we can better understand your concerns and the reasons you are seeking psychological or psychoeducational testing. This will help us determine the type of evaluation needed. Some questions may not apply and it is fine to just answer the question "No" or enter NA for " Not Applicable." The information in this form is guaranteed to be kept confidential and secure. Please remember to click "Submit" when you have finished.
 
    Basic Information
  Your First Name: *
Your Last Name: *
Your Gender: *
Your Birth Date: *
Your Current Grade or Year in College, if applicable: *
Your Name of School or University, if applicable:
Degree or Highest Grade Completed:
Name of School or University where Highest Grade Completed:
Address: *
City: *
State: *  
ZIP: *
Phone: *
Alternate Phone:
Email: *
Emergency Contact (Name, Relation, Email, Phone, etc): *
Will you be the financial guarantor for this evaluation? If no, please list the individual(s) who will be responsible for payment *
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, phone number, and email of referral source:
Referral Name:
Referral Phone:
Referral Email:
It can sometimes be helpful for a young adult to have his/her parents complete a similar form to this one and give information about your developmental and/or school history. Would your parents be available to complete the form or do you want them to be involved? If yes, please list name and contact info:
Briefly describe the reason for referral, your concerns, or a little about your current difficulties:

    Pregnancy/Developmental History:
Were you adopted? If yes, please indicate at what age and any special circumstances that you know (e.g. foreign or domestic adoption, conditions of orphanage, suspected abuse or neglect, etc.):
Are you aware of any illnesses or complications with your mother's pregnancy with you? If yes, please explain:
Were you born full-term? If no, how many weeks gestation and weight at birth (if known)?
Describe any problems related to your birth (if known):
Describe any concerns or problems regarding your infancy or early childhood development (if known):

    Academic Information:
Do you have concerns about your academic progress (if in school)? If yes, please describe briefly:
Did you ever receive special education services or were you ever evaluated by the school system that you remember?
(i.e. to determine eligibility for IEP or special services)? If yes, do you remember the outcome?
Did you ever receive specialized tutoring services or other services such as speech-language therapy or occupational therapy services? If yes, please describe briefly:
Have you ever been previously diagnosed with learning difficulties (e.g. ADHD, LD). If yes, by whom?
Have you ever been tested for mental health or learning concerns previously? If yes, when was the testing done and by whom (i.e. school system, private evaluator, hospital)?
Names of schools and years attended:  
Elementary:
Middle:
High School:
College:

    Occupational Information:
Are you currently employed? If so, where? Please list job title, duties, and length of employment:
Do you have any concerns about your current job/occupation? If unemployed, do you have any concerns about your ability to enter or re-enter the work force? Please describe any concerns related to your employment or occupation:

    Behavioral Concerns
Are you concerned about your behavior at home, in school, at work, or in the community? Is anyone else concerned about your behavior? If yes, Please describe briefly:
Briefly describe any suspensions, expulsions, or disciplinary actions you had in school:
Briefly describe any behavioral concerns, including violent or aggressive behavior, involvement with legal authorities, or history of running away:
Please describe any history of substance abuse, including frequency/severity:

    Emotional Concerns
Are you concerned about your emotional status or self-esteem? If yes, please describe briefly:
Are you concerned about your mood or level of anxiety? If yes, please describe:
Have you been previously diagnosed with any emotional problems (e.g. Depression, Anxiety, Social Phobia, Panic Disorder, etc.)? If yes, please describe:
Describe any major traumatic events or changes in your life (e.g. abuse, illness, death, difficult moves, difficult transitions to new schools, etc.)
Have you ever been hospitalized for psychiatric/psychological reasons? If yes, please describe circumstances, dates, and diagnoses:
Have you ever expressed suicidal ideation or engaged in any self-harm? If yes, please describe circumstances and dates:

    Medical Concerns
Do you have any chronic or recent medical concerns? (e.g. chronic ear infections when younger, PE tubes, asthma, allergies, cerebral palsy, diabetes, food allergies, etc.) Please describe history and treatment:
Have you experienced any concussions or head injuries or had numerous visits to the ER? If yes, please describe:
Have you had any surgeries? If yes, please describe:
Are you currently taking any medications? If so, please list and describe any side effects:
Name of Primary Care Physician:
Approximate date of last vision/hearing screening and indicate if results were normal or abnormal:

     Treatment History
Please describe any prior or current treatments, interventions, or therapies (outpatient therapy, psychiatric monitoring, IOP, residential treatment, medication, school-based interventions, etc.):
Name of Psychiatrist or Therapist(if applicable):

    Family Information
Briefly describe your current living arrangements (e.g. apartment, roommates, parents) Indicate if you are satisfied with your living arrangements:
Is any legal action currently underway for you? If yes, please explain:
Your Father's Name and Occupation (optional):
Your Mother's Name and Occupation (optional):
Your Stepfather's Name and Occupation (optional):
Your Stepmother's Name and Occupation (optional):
Your siblings (number of siblings, names and ages):
Briefly describe any significant family information, such as parent-child conflict, marital discord, or significant discord between family members:
Have you recently moved or changed schools? (If so, describe):
Is there a family history of learning or mental health concerns (e.g. ADHA, dyslexia, depression, OCD, etc)? If so, who?:
Please list your strengths, hobbies, interests, achievements, or positive traits:

Although you may not know or remember, please scan through the following list and check if you remember having any of the following difficulties during childhood or adolescence or if you are continuing to struggle in that area currently. Please check all that apply

Reading
difficulty learning the alphabet difficulty learning to blend sounds
had more difficulty learning to read than expected based on verbal abilities unable to read smoothly
poor tracking mispronunciations
doesn’t understand what is read reads slowly
reverses letters tires easily when reading
resists reading poor recall
 
During Middle School and High School years:
difficulty completing longer reading passages difficulty comprehending longer reading passages
does not grasp the main idea recall of reading passages is poor

Math
poor arithmetic calculation poor sequential procession (doing things in order)
poor understanding of math concepts many careless errors
difficulty learning basic math facts resists math
tires easily when working math difficulty holding numbers in head to work problems
  During Middle School and High School years:
difficulty understanding more complex math of middle school or high school difficulty with geometry and spatial math specifically
does not show his/her work recall of learned math concepts is poor

Writing
difficulty with early handwriting continued poor handwriting
poor spelling letter reversals
difficulty getting thoughts on paper resists writing
writing is laborious, arduous writing below expectation of verbal abilities
difficulty organizing sentences/paragraphs poor punctuation, capitalization
poor use of grammar in writing often does not complete writing assignments
  During Middle School and High School years:
difficulty getting started on essays or papers difficulty organizing thoughts in writing
does not know how to keyboard efficiently difficulty communicating effectively through writing

Motor
difficulty learning to tie shoes difficulty learning to ride a bike
poor fine motor skills poor visual-spatial skills (drawing, copying figures)
poor sense of direction poor balance or coordination
resists sports resists physical activity

Language
articulation problems word retrieval problems
gets tongue-tied difficulty expressing him/herself
has difficulty understanding what is said has difficulty following multi-step directions
seems to have difficulty listening with distractions    

Social
not invited back for playdates or birthday parties prefers one or two close friends to groups
difficulty initiating social interactions difficulty sustaining social interactions
is bullied or teased bullies or teases others
does not read social cues well feels rejected by peers
feels picked on by peers does not seem to get jokes
timing seems a little off acts awkward around peers
difficulty establishing or maintaining friendships difficulty understanding the perspectives of others

Other
talks incessantly becomes easily over-stimulated
does not like tags in clothing is easily startled
does not like certain textures of clothing very picky about food
has muscle or verbal tics has difficulty with transitions
has only a few, narrow interests only wants to talk about one or two things
becomes upset if routine is changed is inflexible, stubborn
over sensitive or under sensitive to sensory input (auditory tactile) poor motor coordination
has specific phobias enuresis (daytime or nighttime bedwetting)
  (List Phobias:)
   

Behavior (Current)
Impulsive Too physically active
Hard time sitting still for long Concerns about behavior in school
Difficulty following directions Defiant or oppositional
Difficulty organizing belongings Forgetful
Careless mistakes Avoids homework
Can't sustain attention for long Does not listen when spoken to
Loses things often Is easily distracted
Fidgety or restless Blurts out answers in class
Has difficulty waiting his/her turn Interrupts others or is intrusive
Difficulty with sleep initiation Difficulty with sleep persistence
Difficulty with early morning awakening Night terrors
Sleep walking    

Developmental: Although you may not know your developmental history, please scan through the following list and check if you remember hearing anyone describe that you had any of the following developmental concerns during infancy or toddlerhood through age 4 or 5. If you do not know, you can leave this section blank.

Expressive language delayed:
No babbling by 9 months No single words by one year
No phrase speech by 18 months Only a few words by age 2
Repeated or echoed phrases without communicative intent (echolalia) Articulation poor or very difficult for others to understand
Initial language delayed but then progressed rapidly by age 3.5    

Receptive language delayed:
Did not respond to simple requests (e.g. "Come here") by 1 year Did not wave "bye bye" or clap hands by 1 year
Did not attempt to communicate by pointing by 14 months Did not understand simple words (e.g. "ball", "snack") by 18 months
Did not understand simple commands (e.g. "Get your shoes") by age 2 Did not use gestures or pointing to communicate
Did not look at people when they were talking Poor eye contact in general

Motor skills:
Did not sit up independently by 9 months Did not crawl or move around freely by 1 year
Did not walk alone by 18 months Walked on tip toes past age 2
Unusual posturing or hand movements Resisted coloring or drawing in preschool
Did not learn to tie shoes by age 5-6 Did not learn to ride a bike by age 5-6
Clumsy, awkward when running/jumping    

Social/Emotional:
No social smile by 6 months Not cuddly as an infant
Had colic or fussy as baby Did not respond to name by 9 months
Did not look at people when they talked to him/her by 1 year Did not enjoy simple games such as peek-a-boo ir pat-a-cake by 1 year
Did not engage in imaginative play by age 3 Did not engage in cooperative imaginary play with peers by age 3-4
Lined up toys or played with parts of toys (e.g. spinning wheels) Preferred to play by self
Preferred to play with younger children Severe tantrums out of proportion for developmental age
Difficulty self-soothing    

Behavior:
Impulsive Very active for age
Ran about or climbed in situations where that was inappropriate Hard time sitting still for long
Could not sit through a meal by age 4 Concerns about behavior in preschool
Engaged in biting behavior in preschool Difficulty following directions
More defiant than typical for preschool years Morning, afternoon, bedtime routines difficult
Difficulty with sleep initiation Difficulty with early morning awakening
Night terrors Sleep walking

Adaptive Behavior:
Did not drink from cup by 12 months Did not feed self by 18 months
Could not dress self by age 4 Not potty trained by age 3 during day
Bed wetting at night past age 4 Sleep walking
 
*You will have a chance to elaborate on any of the above checked items when you talk with the psychologist.
However, if you want to briefly explain any items, you can do so here:



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