Adult Intake - Kemper & Associates Neuropsychological Services

First Name

Last Name

Age

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Home Phone

Work Phone

Cell Phone

Email address for receiving forms or brief communication

Where may we leave a phone or text message?

In Case of an emergency please notify:

First Name

Last Name

Phone

Relationship

Your History

Never marriedYesNo

Living with someone since

Married since

Separated since

Divorced since

Widowed since

Number of times married

Number of children

Son's ages

Daughter's ages

Significant other Name

Age

Occupation

Excluding yourself, who lives in your household?

Name of your referring doctor for evaluation

Phone number of your referring doctor

Will your evaluation be requested by anyone besides your referring physician?YesNo

Will your evaluation be requested by an attorney or used for legal purposes?YesNo

Is there a history of this problem or a precipitating event?YesNo

If yes, what?

Have you had a previous evaluation?YesNo

If yes, with who?

List current or chronic medical problems.

Have you had neuroimaging (MRI/CT/PET), EEG, or lab work done in the last year?YesNo

If yes, list results:

Current Prescriptions, Dosages, Date Prescribed:

Allergies:

History of trauma or abuse (physical, sexual, or emotional)

Educational Background (include highest level of education)

Occupational Background (include jobs held for past 5 years/if retired then when retired and how long in that occupation)

Have you served in the military?YesNo

If yes, please list dates of service and discharge rank

History of arrests, court proceedings or other legal issues which have you have been involved:

Previous Counseling (including provider names, dates and place)

History of medications for emotional/substance abuse problems

What current social, family, spiritual, or other supports do you have?

What coping strategies/hobbies do you have?

Please rate your substance use for the following:

0 = no use 1 = use, please list how much and how often 2 = addiction 3 = currently in treatment

Alcohol

Illicit drugs

Tobacco

Caffeine

Past use of drugs (specify)

When last used

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623-312-3713

Background Info for Adults

In Case of an emergency please notify:

Your History

Please rate your substance use for the following:

0 = no use 1 = use, please list how much and how often 2 = addiction 3 = currently in treatment