Pediatric Neuropsychological Assessment Intake Questionnaire
Please complete this form to provide background information for your child's neuropsychological evaluation.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Referral
*
Current Concerns (Select all that apply)
*
Attention/Concentration
Learning/Academic Skills
Memory
Language/Communication
Motor Skills/Coordination
Behavioral/Emotional Issues
Social Skills
Other
Developmental Milestones
Rows
Achieved on time
Delayed
Not sure
Sat without support
1
2
3
Walked independently
4
5
6
First words
7
8
9
Toilet trained
10
11
12
Medical History (Check all that apply)
Seizures
Head Injury
Premature Birth
Chronic Illness
Vision/Hearing Problems
None
Other
Educational History: Please indicate any of the following that apply to your child
Receives special education services
Has an Individualized Education Program (IEP)
Repeating a grade
Behavioral issues at school
None of the above
Other
Please rate the following behaviors for your child
Rows
Never
Sometimes
Often
Very Often
Difficulty sitting still
13
14
15
16
Easily distracted
17
18
19
20
Mood swings
21
22
23
24
Difficulty with peers
25
26
27
28
Anxiety
29
30
31
32
Impulsivity
33
34
35
36
Family History: Does anyone in the family have a history of any of the following? (Check all that apply)
Learning difficulties
Attention/Hyperactivity issues
Mood disorders
Developmental disabilities
None of the above
Other
Submit Intake Questionnaire
Should be Empty: