Minor Intake - Kemper & Associates Neuropsychological Services

Child's First Name

Child's Last Name

Today's Date

Age

Grade Level

Date of Birth

Left or Right Handed?

Parent Information for Who is Completing the Form

Parent's First Name

Parent's Last Name

Age

Date

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Alternate Phone

Where may we leave a phone or text message?

Email address for receiving forms or brief communication

Emergency Contact

First Name

Last Name

Phone

Relationship

Name of Referring Doctor for Evaluation

Phone of Referring Doctor for Evaluation

Will your child's evaluation be requested by anyone else besides the referring physician?YesNo

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

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

Was there a previous evaluation? If yes, with who and when?

Family Status

Mother's First Name

Mother's Last Name

Age

Occupation

Father's First Name

Father's Last Name

Age

Occupation

Legal Guardian (If not parent)

Parents Currently:MarriedSeparatedDivorcedNot Married

If Divorced, who has custody?MotherFatherBothOther

Both parents living?YesNo

If no, please explain:

List everyone in household(s)

Sister(s) age

Brother(s) age

Family History

Please list any family history of medical problems:

Please list any family history of mental health problems:

Please list any family history of substance abuse problems:

Please list any family history of legal problems:

Developmental History

Is your child 12 years old or younger?If yes, please complete the Developmental History Questionnaire. If no, please complete the following information:

Please list any complications or unusual birth circumstances or development concerns:

Social History

Please list any problems or concerns with social interactions:

Does your child have a history of being bulled or bullying others? If yes, please provide details:

What hobbies, sports, or clubs does your child enjoy?

What coping strategies does your child currently use?

Is your child dating currently or have a history of dating?

What after school jobs has your child had?

Health Status and History

Current or Chronic Health Problems

Current medications, including over-the-counter

Any history of hospitalizations (including dates/places/reason):

Any history of surgeries or head injury:

Mental Health Status and History

Previous Counseling (including dates & places)

Previous hospitalization for emotional or substance abuse problems

History of medications for emotional/substance abuse problems

Education Status and History

School Attending

What kinds of problems have teachers reported at school?

What kinds of problems does your child report regarding school:

Is there a history of a 504Plan or IEP? If yes, please provide specifics of the plan:

Trauma/Abuse History

Please list any history of Trauma:

Has Department of Child Safety been involved with your child? If yes, please indicate the circumstances:

Legal History

Has your child been in any kind of legal problem? If yes, please provide details:

Substance Use (0=no use, 1=occasional, 2=moderate, 3=heavy, 4=addiction, 5=currently in treatment)

Alcohol

Tobacco

Caffeine

Illicit Drugs (specify)

Past Use of Drugs (specify)

Other Concerns

Please list any other concerns not already noted above:

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Background Info for Children