Assessment Intake/History Form

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Assessment Intake/History Form PATIENT INFORMATION Patient Name: Date of Birth: Age: Parent/Guardian Name(s): Who has legal custody of this child? Please circle one of the following: Address: City, State, Zip Code: Home Phone: Mobile Phone: Work Phone: Email: biological child / adopted / foster child REFERRAL SOURCE Name, Degree Organization: Phone Number: TREATMENT PROVIDERS: Primary Care Physician/Pediatrician: Name / Organization / Telephone Number Psychiatrist/Psychopharmacologist: Neurologist: Outpatient Therapist: Family Therapist: In-Home Therapist: Community Service Agency (CSA): Other (please indicate):

MPC Intake/History Form, Page 2 of 7 FAMILY INFORMATION NAME RELATIONSHIP TO PATIENT OCCUPATION/GRADE Living with the patient? Parent/Guardian Relationship: Married [ ] Divorced [ ] Separated [ ] Unmarried [ ] Single [ ] FAMILY MEDICAL HISTORY Please indicate any of your child's biological relatives who have had the following conditions: CONDITION seizure disorder attention issues/hyperactivity depression anxiety bipolar disorder anger management problems psychosis/schizophrenia RELATIONSHIP TO PATIENT CONDITION intellectual disability autism/asperger s disorder communication/language issues social difficulties school/learning disabilities alcohol/substance abuse other (please specify) RELATIONSHIP TO PATIENT Name of birth mother: Birthplace: BIRTH HISTORY Was this a planned pregnancy? Please indicate use of the following during pregnancy: Cigarettes [ ] Alcohol [ ] Mother's medication [ ] Other substance [ ] Birth was: Full Term [ ] Premature [ ] (at weeks) Delivery was: Normal/Vaginal [ ] Cesarean [ ] Please describe any pregnancy or birth complications:

MPC Intake/History Form, Page 3 of 7 INFANCY: Feeding issues Sleeping issues Overactive Difficult to calm/soothe Cheerful Affectionate LANGUAGE DEVELOPMENT: Age of his/her first words: Age he/she began using sentences: Describe any history of hearing problems: Does your child have difficulty listening? Does your child have speech/talking problems? Does your child have difficulty communicating or finding words? Has your child had a Speech/Language Evaluation? - please state when and by whom: - please summarize the results: Has your child received Speech/Language Therapy? -please state when and by whom: MOTOR DEVELOPMENT: Age he/she began crawling: Age he/she began walking: Age he/she was successfully toilet trained: Has your child ever had fine motor issues (writing, using utensils, etc.)? - if yes, please describe: Has your child had an Occupational Therapy (OT) Evaluation? - please state when and by whom: - please summarize the results: Has your child received Occupational Therapy (OT)? -please state when and by whom: Has your child ever had any gross motor issues (walking, balancing, etc.)? - if yes, please describe Has your child had a Physical Therapy (PT) Evaluation? - please state when and by whom: - please summarize the results: Has your child received Physical Therapy (PT)? -please state when and by whom:

MPC Intake/History Form, Page 4 of 7 EDUCATIONAL HISTORY: Current Grade: Please list any repeated grades: Name of current school: Name of teacher or contact: My child has previously had a: 504 Plan [ ] IEP [ ] My child currently has a: 504 Plan [ ] IEP [ ] Date of CORE evaluation: When were the last SPED assessments: Please indicate classroom setting: Completely mainstream [ ] Mainstream with pullout support [ ] Half mainstream, half separate class [ ] Substantially separate classroom [ ] Please indicate current areas of support: Reading [ ] English/Language Arts (ELA) [ ] Writing [ ] Math [ ] Counseling [ ] MEDICAL HISTORY: Please describe any previous head injuries: Please list any previous surgeries: Please list any major previous illnesses: Please list any chronic medical issues: CURRENT MEDICATIONS: MEDICATION DOSE PRESCIBER REASON

MPC Intake/History Form, Page 5 of 7 MENTAL HEALTH HISTORY PREVIOUS DIAGNOSES WHEN BY WHOM Please list any inpatient psychiatric admissions, where, and when: Please list any residential/cbat admisstions, where, and when: Please list and partial hospitalization program (PHP) admisstions: Please describe current concerns for your child, and what specific questions you hope this evaluation will answer:

MPC Intake/History Form, Page 6 of 7 SYMPTOM CHECKLIST Can't follow directions Currently [ ] In the past [ ] Difficulty focusing Currently [ ] In the past [ ] Hyperactive Currently [ ] In the past [ ] Can't control impulses Currently [ ] In the past [ ] Problems sustaining effort Currently [ ] In the past [ ] Problems facing challenges Currently [ ] In the past [ ] Problems going to sleep Currently [ ] In the past [ ] Frequent nightmares Currently [ ] In the past [ ] Excessive anxiety Currently [ ] In the past [ ] Panic attacks/specific fears Currently [ ] In the past [ ] Repeats certain actions Currently [ ] In the past [ ] Can't stop thinking about things Currently [ ] In the past [ ] Frequent headaches/stomachaches Currently [ ] In the past [ ] Preoccupations with ideas or objects Currently [ ] In the past [ ] Gets upset by changes in routine Currently [ ] In the past [ ] Often irritable Currently [ ] In the past [ ] Often sad or depressive Currently [ ] In the past [ ] Sensitive/cries easily Currently [ ] In the past [ ] Thinks or talks about death Currently [ ] In the past [ ] Thinks of talks about suicide Currently [ ] In the past [ ] Extreme mood swings Currently [ ] In the past [ ] Excessive giddiness Currently [ ] In the past [ ] Self-injurious behavior Currently [ ] In the past [ ] Often defies adult rules Currently [ ] In the past [ ] Strong reaction to hearing "no" Currently [ ] In the past [ ] Often angry or resentful Currently [ ] In the past [ ] Often loses temper Currently [ ] In the past [ ] Blames others for mistakes Currently [ ] In the past [ ] Refuses to go to school Currently [ ] In the past [ ] Has been bullied Currently [ ] In the past [ ] Has been a bully Currently [ ] In the past [ ] Has been in physical fights Currently [ ] In the past [ ] Has harmed animals Currently [ ] In the past [ ] Has started fires/destroyed property Currently [ ] In the past [ ] Problems with lying Currently [ ] In the past [ ] Problems with stealing Currently [ ] In the past [ ] Over reactive to noise or touch Currently [ ] In the past [ ] Problems socializing Currently [ ] In the past [ ] Difficulty keeping friends Currently [ ] In the past [ ] Expresses strange/bizarre ideas Currently [ ] In the past [ ] Motor or vocal tics Currently [ ] In the past [ ] Use of alcohol of drugs Currently [ ] In the past [ ]

MPC Intake/History Form, Page 7 of 7 WHAT PARENTS/GUARDIANS CAN EXPECT The process of seeking and completing this type of evaluation takes time and collaboration. Here s what you can expect and what you will need to make this process as easy as possible for your family: STEP 1: Complete the MPC Intake/History Form and mail/fax it back to MPC. Upon receipt of these materials, we will call you to schedule an intake appointment. o Mailing address: Medical Psychology Center 100 Cummings Center, Suite 456J Beverly, MA 01915 Tel: (978) 921-4000 Fax: (978) 921-7530 o Please include copies of any of the following, if applicable: Referral letter from your PCP/Psychiatrist/Neurologist (dictated by your insurance plan) Most recent Individualized Education Program (IEP) or 504 Plan Any previous school-based assessment reports (If your child receives SPED services, these assessments were completed.) Any reports for previous neuropsychological or psychological assessments Proof of Guardianship Documentation STEP 2: Intake Appointment (approx. 45min. and just for parents/guardians) o During this appointment we will discuss your concerns for your child and what questions you hope this assessment will answer. We ll also discuss how we conduct our assessments and review any insurance related forms. STEP 3: Evaluation Appointment o This appointment is when we work with your child and takes several hours. We will discuss ahead of time what specific needs your child may have, and how we can custom the day to accommodate them (and you!). STEP 4: Feedback Appointment (approx. 45 min. and just for parents/guardians) o This is an important meeting because it is when we discuss all of the results from the evaluation, diagnosis, and recommendations. Depending on the case, adolescent patients may benefit from being included. STEP 5: Report o Following the feedback appointment, and once payment has cleared, we will send you a report that includes all of the information covered in the feedback, in detail.

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