Child Psychological Evaluation Intake Questionnaire
Please complete this form to provide background information for your child's psychological evaluation. All information is confidential and will help us better understand your child's needs.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Grandparent
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
*
example@example.com
Reason for Referral (please select the main concerns)
*
Behavioral concerns
Emotional concerns
Academic/learning difficulties
Developmental delays
Social difficulties
Other
Please rate the severity of your concerns regarding your child
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Please provide a brief description of your main concerns about your child
*
Developmental, Medical, and Family History
*
Rows
Yes
No
If yes, please describe
Has your child had any significant medical conditions or hospitalizations?
1
2
Has your child previously received psychological or educational evaluations?
3
4
Are there any family members with learning, behavioral, or emotional difficulties?
5
6
Current School/Daycare Name
Grade/Year in School
Please Select
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
High School
Other
Has your child received any previous therapies or support services? If yes, please describe.
Is there anything else you would like us to know about your child?
Submit
Should be Empty: