adult/teen pre-evaluation questionnaire · 2019. 8. 6. · –adult/teen pre-evaluation...
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Adult/Teen Pre-Evaluation Questionnaire
Person Being Evaluated (“Client”) Person Assisting in Completion of Questionnaire
Name: ___________________________________ Name: ______________________________________
Date of Birth: ____________Dominant Hand:_____ Relationship to Client: ___________________________
Please read these directions before you begin.
Please take your time completing this questionnaire as thoroughly and accurately as you are able.
If you would like an additional person to also complete the questionnaire to provide another
perspective (i.e. parent, spouse, or friend, etc.), please have him/her use a different color ink.
Return ASAP.
Presenting Concerns
1. What is your major concern that led you to seek help?
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2. What other concerns do you have?
________________________________________________________________________________________
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3. Is there a particular reason you are seeking an appointment now?
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Prior Assessment/Therapy Treatment
4. Have you ever had a psychological evaluation or had intellectual or achievement testing at school?
□ No □ Yes If yes, please describe when, with whom, and the results.
________________________________________________________________________________________
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5. Have you ever been in counseling, or have you ever sought help for these problems before?
□ No □ Yes If yes, please fill in the information below.
Most Recent Counselor: ____________________________________________________________________
Dates attended: ________________________________ Number of Sessions attended: ______________
Details (Goals of therapy, results of therapy, etc.): _______________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Any Previous Counselor(s): __________________________________________________________________
Dates attended: ________________________________ Number of Sessions attended: ______________
Details (Goals of therapy, results of therapy, etc.): _______________________________________________
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Medication History
6. Have you ever taken medication for attention, behavior, mood, or other psychological reasons?
□ No □ Yes If yes, fill out the table below as completely as possible for each medication.
Medication
Dose
Reason Prescribed
Dates Taken
Prescribing Physician
Benefits
Negative Side Effects
If discontinued, why?
7. Are you currently taking any medication for medical reasons?
□ No □ Yes If yes, fill out the table below as completely as possible for each medication.
Medication
Dose
Reason Prescribed
Date Started
Prescribing Physician
Negative Side Effects
8. Are you in the process of or would you like to be making any medication changes?
□□ No □□ Yes If yes, please describe.
_______________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Medical History
9. Have you been to the doctor in the last year?
□ No □ Yes If yes, were the current concerns discussed? Were recommendations made?
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10. How is your health currently? Are you being treated for anything?
________________________________________________________________________________________
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11. Do you get headaches? □ No □ Yes If yes, please describe the type, frequency, and severity.
________________________________________________________________________________________
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12. What medical or physical problems have you had? Mark an X where appropriate.
Birth - 5 6-12 13-18 19-24 25-50 50+
Very sensitive to textures in clothes (seems, labels, etc)
Allergies or food sensitivities
Ear infections, frequent colds
Poisoning or drug overdose
Serious illnesses or surgeries
Vision/hearing difficulties (not glasses)
Speech disorders
Serious accidents/Injuries
Any blows to the head or concussions
Any loss of consciousness or seizures
Bothered by loud/unexpected noises
Very picky eater
Please describe any X that was marked:
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– Adult/Teen Pre-Evaluation Questionnaire
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Developmental History
13. Were there any problems or unusual circumstances during the pregnancy, delivery, or first months of your
life?
□ No □ Yes □ Don't know If yes, please describe.
________________________________________________________________________________________
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14. Were you adopted? □ No □Yes
If yes, at what age were you adopted? ________________________________________________________
If yes, when did you learn that you are adopted? ________________________________________________
15. Were there any developmental problems including delay in learning to crawl, walk or talk?
□ No □ Yes □ Don't know If yes, please describe.
________________________________________________________________________________________
________________________________________________________________________________________
16. As an infant, were you told you were difficult, demanding, hard to soothe, colicky or had problems sleeping?
□ No □ Yes □ Don't know If yes, please describe.
________________________________________________________________________________________
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17. Were there any disruptions or major difficulties that could have affected your bonding with your mother
during the first three years?
□ No □ Yes □ Don't know If yes, please describe.
________________________________________________________________________________________
18. As a child, were your said to have been extremely physically active or always “on the go”?
□ No □ Yes □ Don't know If yes, please describe.
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Social relations and support
19. How well did you get along with your parents while growing up?
Mother:_________________________________________________________________________________
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Father::__________________________________________________________________________________
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20. How close are you to your parents and siblings now?
________________________________________________________________________________________
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21. If you are married or in a serious relationship, how would you evaluate your marriage/relationship?
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22. How strong a network of friends do you have?
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23. Are you active in a faith?
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24. What other sources of personal strength do you call upon to face problems?
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25. Do you, though not shy, prefer to be alone or show little interest in having close relationships with peers
outside family?
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– Adult/Teen Pre-Evaluation Questionnaire
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Academic History
26. What is the furthest grade reached or highest degree attained in school? ____________________________
27. Where did you receive your most recent schooling? ______________________________________________
28. What was the Grade Point Average in your last schooling? _________________________________________
29. Please put an “x” next to any of the following that are current problems:
Difficulty learning to read, blend sounds or read smoothly Difficulty at written composition
Problems tracking while reading (losing place, missing words) Difficulty spelling
Difficulty remembering what was read Poor sense of direction
Poor handwriting (even if writing slowly) Difficulty drawing or copying figures
Difficulty understanding math concepts Difficulty with math calculations
Other memory concerns
30. Please describe your greatest strengths and any special abilities or talents.
________________________________________________________________________________________
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31. Please mark with an "X" when any of the following has occurred.
Grades
K-5th
Grades
6-8
Grades
9-12 College
Post-
College
Reading difficulties
Math difficulties
Writing difficulties
Poor grades
Homework problems
Behavior problems at school
Peer Problems
Strongly disliked school
Resource or other remedial assistance
Special Education placement
On Individualized Education Plan (IEP)
In Gifted Program (GIEP)
32. What things have you tried at home to solve any of the problems noted above?
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– Adult/Teen Pre-Evaluation Questionnaire
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Work History
33. Are you currently employed? □ No □Yes
If yes, where do you work? ___________________________________ □ Full Time □ Part-Time
If yes, what do you do? _____________________________________________________________________
34. How long have you been at your current job? __________________________________________________
35. Describe any problems you have had with work performance issues:
________________________________________________________________________________________
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36. Describe any problems you have had with work satisfaction issues:
________________________________________________________________________________________
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Attention
37. What problems do you have with daydreaming, staying on-task or being disorganized? At what age did you
first notice this? Do the problems occur mainly at home, at school or work or in all places?
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38. What problems do you have with hyperactivity, stimulus seeking or feeling restless? At what age did you
first notice this? Do the problems occur mainly at home, at school or work or in all places?
________________________________________________________________________________________
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39. What problems do you have with impulsivity, impatience or acting without thinking of consequences? At
what age did you first notice this? Do the problems occur mainly at home, at school or work or in all places?
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Oppositionality, Anger, and Conduct
40. What problems do you have with being asked to do small tasks or requests? Are you easily irritated by such
requests? Are you likely to remember the request and actually complete the request if you start it? How
much do you feel that any problems in this area come from not liking to be told to do things versus being
distractible or disorganized?
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41. What problems do you have with irritability and anger? When angry, are you more likely to let the anger go
quickly or hold onto resentment?
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42. Do you ever become violent or destructive? Have you ever hurt anyone intentionally or threatened to kill
someone? Have you ever been cruel to animals? What interest do you have in weapons?
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43. What problems do you have with getting into trouble, unlawful activity, or delinquent actions that could
cause legal consequences?
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44. In relating to others, what problems, if any, do you have in terms of lacking empathy, being manipulative, or
failing to show remorse when appropriate?
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– Adult/Teen Pre-Evaluation Questionnaire
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Depressive Symptoms
45. What problems do you have with your feelings being too easily hurt? Are there any signs of problems with
self-esteem? Are there particular things about yourself you feel especially bad about?
________________________________________________________________________________________
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46. What problems, if any, do you have with sadness, moodiness, withdrawing from friends or activities,
appearing down, lacking motivation or enthusiasm, changes in eating pattern, loss of sex drive, crying easily,
or other signs of depression?
________________________________________________________________________________________
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47. To what extent do you tend to think that life is not worth living or that death would be welcome?
________________________________________________________________________________________
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Somatic Problems
48. What problems do you have with muscle or verbal tics? These are repetitive movements or noises such as
eye blinking, facial twitching, or noises such as grunting, snorting, squeaking, or humming.
________________________________________________________________________________________
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49. Have you struggled with chronic pain, sickness, or medical problems over the course of your life?
________________________________________________________________________________________
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50. In what ways does stress in your life cause physical symptoms such as back or neck aches, headaches,
intestinal problems, or dizziness? How has that changed over time?
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Anxiety
51. What problems do you have with fears, tension, anxiety, panic attacks, phobias, being very uncomfortable in
new situations, or extreme shyness? How has that changed over time?
________________________________________________________________________________________
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52. Has anything ever happened to you that when recalled causes you extreme distress? Are there any such
events that continue to cause bad dreams?
□ No □ Yes If yes, please describe.
________________________________________________________________________________________
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53. Are there any ideas, fears or concerns about which you obsess or worry?
□ No □ Yes If yes, please describe.
________________________________________________________________________________________
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54. Do you have any habits, rituals or other compulsive behaviors?
□ No □ Yes If yes, please describe.
________________________________________________________________________________________
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55. Do you tend to become overly fascinated by one particular topic, or become an expert in one particular
subject to the point that it is all you want to talk or learn about?
□ No □ Yes If yes, please describe.
________________________________________________________________________________________
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Psychosocial History
Please describe ONE, any of the following the you experienced, TWO, the impact you felt the events had on you
then and THREE, how you feel it may be affecting you now.
Problem Areas Age(s) (1) Nature of event, (2) Impact THEN, (3) Impact NOW
Problems in the family such as
separation, divorce or
remarriage; psychiatric, alcohol
or drug problems of parent,
death or serious health
problems of family member;
change in living arrangements
Emotional, physical, or sexual
abuse; neglect, or exposure to
domestic violence or on-going
intimidation, harassment,
discrimination
Problems with housing, living
arrangements, such as
homelessness or frequent
moves or sudden loss of
family income
Chronic medical problems,
illness or surgeries
– Adult/Teen Pre-Evaluation Questionnaire
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Problem Areas Age(s) (1) Nature of event, (2) Impact THEN, (3) Impact NOW
Problems in social network
such as death or loss of close
friends rejection by peers, or
frequent moves causing loss of
friends
Educational problems
including learning problems,
academic problems, inadequate
schooling
Is there anything else you would
like to tell us about that may be
affecting your mental health?
Exposure to disaster,
accidents or other trauma
– Adult/Teen Pre-Evaluation Questionnaire
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Sleep
56. Do you feel you could benefit significantly from increasing the amount or quality of your sleep?
□ No □ Yes
57. Please put an “X” next to any of the following that are current problems:
Delays going to bed Difficulty falling asleep Difficulty waking in morning
Physically restless sleep Not rested after sleep Nightmares (bad dreams)
Sleeping too much Frequent waking Teeth grinding
Snoring Bedwetting Sleep Apnea
Please describe the severity and frequency of any “X” that was marked:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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Diet
58. Do you feel you could benefit significantly from improving your Diet?
□ No □ Yes
59. How healthy is your diet? What problems, if any, have you had with sugar cravings, dieting or maintaining
weight? Have you ever tried any special diets?
________________________________________________________________________________________
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Exercise/Activity
60. Do you feel you could benefit significantly from changing your Exercise/Activity routine?
□ No □ Yes
61. How much activity or physical exercise do you get?
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Substance use
62. How much do you use tobacco/smoke cigarettes? _______________________________________________
63. How much do you drink coffee/caffeinated beverages? ___________________________________________
64. How much alcohol do you drink? Describe frequency, quantity, and under what circumstances. Has anyone,
including yourself, expressed concern about your drinking? Have you ever sought help to control or stop
drinking? Was this ever a problem when you were younger? If you don’t drink, what effect did it have if you
ever tried it?
________________________________________________________________________________________
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65. Do you use drugs? Describe frequency, quantity, and under what circumstances. Has anyone, including
yourself, expressed concern about your drug use? Have you ever sought help to control or stop using? Was
this ever a problem when you were younger? Did you ever try any drug that you did not like the effect?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Electronics and Media Use
66. Please complete the table to describe the duration and frequency of your electronics and media use.
Type of Media/Electronics Frequency of Use (hrs/day) Preferred games/shows, websites, etc.
Television
Video Games
Computer Games
Social Media
Other:
Menstruation (females only)
67. (Females only) What problems, do you have with unusual depression, irritability or discomfort during the
week or so before the menstrual period?
________________________________________________________________________________________
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– Adult/Teen Pre-Evaluation Questionnaire
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Family History
68. Check here if your birth Mother’s family history is unknown: □
69. Check here if your birth Father’s family history is unknown: □
70. Do any of your blood relatives have issues with any other following?
Problems Area Relatives (children, siblings, parents, grandparents, aunts or
uncles) who may have had problems in the area
M-Mom’s side F-Father’s side
Example Row One of Mom's sisters took medication for “Example” and one of Dad's brothers was treated for “Example” from age 15 to 40
M / F
Problems with distractibility,
hyperactivity or impulsivity.
Problems learning to read,
write or do math.
Problems with opposionality, anger, violence or crime.
Depression
Anxiety
Headaches or Migraines
Seizures or Neurological
problems
Alcohol Abuse
Drug Abuse
Serious Medical Problems
Serious Mental or Emotional
Illness
Thank you for completing this form! Please bring it with you to the office on the first day of your evaluation!