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.): _______________________________________________

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Any Previous Counselor(s): __________________________________________________________________

Dates attended: ________________________________ Number of Sessions attended: ______________

Details (Goals of therapy, results of therapy, etc.): _______________________________________________

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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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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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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?


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16. As an infant, were you told you were difficult, demanding, hard to soothe, colicky or had problems sleeping?


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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?


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18. As a child, were your said to have been extremely physically active or always “on the go”?


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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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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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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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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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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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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?


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54. Do you have any habits, rituals or other compulsive behaviors?


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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?


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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


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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


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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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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?

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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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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!

adult/teen pre-evaluation questionnaire · 2019. 8. 6. · –adult/teen pre-evaluation...

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