Assessment Intake Form Assessment Intake Form
Instructions:
This form can be completed online sent to the clinic with a push of a button at the bottom of the form or saved to your computer and emailed to: psychologicalassessments@ncpac.info
If either of these methods are not possible, it can be mailed to:
Suzanna Fletcher
7207 Sheriff Watson Rd.
Sanford, NC 27332
It is important to complete and send this form at least 4 days prior to the intake appointment. If it is being sent via traditional mail (USPS), please send it at least 7 days prior to the intake. Thank you greatly!
Client Information Will any persons coming to this evaluation be unable to walk up or down 4 steps and require a ramp to enter the building?
Reason for Evaluation What concerns led you to seek an evaluation at this time for your child?
Who first noticed these concerns, and when?
What specific behaviors, traits, or challenges are most concerning?
What are you hoping to learn or gain from this evaluation?
Developmental History Were there any pregnancy, birth, or early medical complications?
Did the client meet early developmental milestones on time?
Were there any delays or regressions in language, social skills, or other development?
If yes, please describe (note if it was a delay or the client had the skill and lost it, as this shows regression)
Describe early concerns related to social behavior (for example: eye contact, response to name, interest in others, pretend play, sharing enjoyment)
Describe any early repetitive behaviors, strong routines, unusual or focused interests, and any negative behaviors that occur if these are interrupted.
List any sensory sensitivities noticed in early childhood and currently
- Select - Early childhood sensory sensitivities (sensitivity to sounds, lights, textures, smells, food tastes, or others) Current sensory sensitivities (sensitivity to sounds, lights, textures, smells, food tastes, or others) Sensory seeking behaviors (spinning, jumping, chewing, banging into furniture on purpose,
Current Communication and Social Interaction How does the client typically communicate needs, feelings, and ideas (single words, phrases, sentences, pointing, showing, or others?
Are there concerns with any of the following?
- Select - Understanding social cues Back-and-forth conversation Eye contact Atypical facial expressions or flat affect Atypical tone of voice Making or keeping friends Understanding humor, sarcasm, or figurative language
Please describe the client’s challenges in communication and social interaction that were not listed above.
Please describe the client’s strengths in communication and social interaction.
Behavior Does the client show any of the following?
- Select - Repetitive movements (rocking, hand flapping, pacing, etc.) Repeating words or phrases Strong need for routines or sameness Distress with changes in plans
What other situations tend to trigger distress, shutdowns, or meltdowns, if applicable?
What helps the client feel calm, regulated, or supported?
Focused Interests Please describe any focused interests (interests the client fixates on)
Is it difficult for the client to transition from a focused interest to another task or leisure activity? If so, what behaviors occur during this transition.
Below are just a sample of symptoms in each area. These are not conclusive lists.
Please put a “yes” after symptoms that occur often to frequently and a “no” after symptoms that occur never to sometimes.
Hyperactivity Persistent fidgeting or restlessness,
Difficulty remaining seated,
A strong need to stay active
Struggling to wait their turn
Acting or speaking without considering consequences
Making impulsive decisions
Inattention Forgetting everyday responsibilities
Difficulty sustaining attention
Difficulty following multi-step instructions
Difficulty organizing tasks
Difficulty completing regular routines
Anxiety Nervousness before participating in novel activities
Nervousness before going to novel environments
Difficulty separating from parent, caregiver, or sibling
Restlessness or feeling on edge
Difficulty concentrating or the mind going blank
Often needing reassurance
Depression Depressed mood or irritability most of the day, nearly every day
Markedly reduced interest or pleasure in most activities
Temper outbursts, expressed verbally or behaviorally If present, how often do these occur?
Significant appetite change
Significant weight gain or loss
Fatigue or loss of energy
Feelings of worthlessness
Excessive or inappropriate guilt
Reduced ability to think, concentrate, or make decisions
Recurrent thoughts of death, suicidal thoughts, a suicide attempt, or a suicide plan.
Educational History Has the client received any academic accommodations?
Are there concerns with any of the following? If yes, please briefly describe.
Medical History
Mental Health History Has the client ever received speech therapy, occupational therapy, behavioral services, counseling, therapy, psychiatric medications, or others?
If yes, please list provider(s), dates, and reason for treatment to the best of your ability:
Previous neurodevelopmental or mental health diagnoses, if any:
Any history of trauma, major stressors, or significant life events relevant to functioning?
If yes, please briefly describe:
Family History Is there a family history of any of the following? If yes, list the relationship to the client (immediate family member, cousin, aunt, uncle, grandparent, other) if you feel comfortable doing so
Strengths and Interests What are the client’s greatest strengths?
What environments or approaches help the client thrive?
Current Functioning How are the concerns named above affecting home life, school, work, relationships, or daily functioning?
Records and Collateral Information Please list any records or reports available for review:
Is there any other information you would like to share?
Share any other information you would like
Consent and Signature
I certify that the information provided in this intake form is accurate and complete to the best of my knowledge.
Signature (if possible; if not possible, please type your full name):
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