Client Case History Questionnaire

The information requested on this questionnaire is required as part of your evaluation. Please feel free to add as much
information as you want. Use the backs of pages if necessary.

The highest standards of professional confidentiality are maintained. Information about any particular client can be
released only with the explicit written consent of that person except in exceptional legal situations.

Identifying Information

Name: SS#:
Last First MI Preferred Last four digits only

Address: Birthdate:

Home Phone:
City State Zip Code May we leave a voicemail? □ yes □ no

Cell Phone:
May we leave a voicemail? □ yes □ no

Ethnicity: Marital Status: Gender:

Who is filling out this form? Today's Date:

Who will be responsible for scheduling testing sessions?

Date of your last psychological evaluation? Please provide copies of all reports.

By whom?

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Birth History

1. Maternal history of miscarriage? Stillbirths?

Please indicate when miscarriages and/or stillbirths occurred in relation to your birth.

2. Pregnancy with you:

Bleeding: □ yes □ no Illness: □ yes □ no Infections: □ yes □ no

Accidents: □ yes □ no RH Incompatibility: □ yes □ no

Length of Pregnancy: Was the delivery □ early □ on time □ late By how much?

Medications Taken? □ yes □ no What?

Explanation of unusual circumstances?

3. Birth of Client

Labor: False? □ yes □ no Induced? □ yes □ no Length?

Anesthesia? □ yes □ no Natural? □ yes □ no

Type of Birth: Normal? □ yes □ no Dry? □ yes □ no Breech? □ yes □ no

Forceps? □ yes □ no Caesarean? □ yes □ no Birthweight?

Complications:

Apgar Score (if known):

Color: Normal? □ yes □ no Blue? □ yes □ no Jaundiced? □ yes □ no

Transfusions? □ yes □ no Incubator required? □ yes □ no How long?

Difficulties sucking, swallowing or feeding? □ yes □ no Explain.

Explanation of unusual circumstances?

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Developmental History

1. At what age did you:

Say your first word? Sit unassisted?

Understand speech? Walk unassisted:

Use 2-word sentences?

Stop using "baby" talk?

2. Did your family, friends, teachers, etc. ever have difficulty understanding your speech? □ yes □ no

If so, please explain.

3. What skills were hard for you to learn as a preschooler?

4. Did you receive therapy? □ speech □ physical □ occupational Age: ______ How long? _______________

Medical History

1. Have you ever been diagnosed with the following:

Measles? □ yes □ no Age Explain:

Meningitis? □ yes □ no Age Explain:

Encephalitis? □ yes □ no Age Explain:

Whooping Cough? □ yes □ no Age Explain:

Scarlet Fever? □ yes □ no Age Explain:

Many Ear Infections? □ yes □ no Age Explain:

Chicken Pox? □ yes □ no Age Explain:

Pneumonia? □ yes □ no Age Explain:

Frequent Colds? □ yes □ no Age Explain:

Allergies? □ yes □ no Age Explain:

Others? □ yes □ no Age Explain:

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2. Have you ever received any blows to the head that required treatment in a hospital or emergency room?

□ yes □ no When?

Were you unconscious? □ yes □ no For how long?

How did it happen?

3. Have you ever had seizures? □ yes □ no At what age?

Did you receive medication? □ yes □ no Specify:

When was your last seizure?

Known cause for seizures?

4. Have you ever had injuries or accidents requiring medical treatment? □ yes □ no
Specify:

5. Have you ever been medically hospitalized? □ yes □ no When? _________ How long? _______________

Purpose?

6. Were there any changes in thinking, behavior, or school performance following illnesses, blows to head, seizures,
injuries or hospitalizations?

□ yes □ no Specify: ______________________________________________________________________

7. Have you ever had any of the following medical evaluations? Specify diagnosis and give date.

a. EEG □ yes □ no Specify:

b. CT/MRI □ yes □ no Specify:

c. Neurological examination □ yes □ no Specify:

d. Other □ yes □ no Specify:

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Medical History- continued:

8. Have you used any of the following substances (do not include those taken as prescribed by a medical professional)

Substance Current Use: please check which of If you have ever used this substance,
these you have used in the past 6 at what age did you first use it?
months
Never Sometimes Often 12 or under 13-17 18-22 22 +
Caffeine
Cigarettes
Beer
Wine or wine coolers
Liquor
Marijuana
Cocaine or crack
Hallucinogens (LSD, PCP)
Designer (Bath Salts, K2)
Heroin or opiates
MDMA/Ecstasy
Inhalants (paint, gasoline)
Methamphetamine
OTC (cough syrup, allergy)

Psychiatric History

1. Have you ever been diagnosed with the following? If so, when and by whom (psychologist, school, medical doctor):

Disorders Childhood (before 18) Adult By Whom

Intellectual Disability
Autism Spectrum
Language/Communication
ADHD
Learning- Reading
Learning- Math
Learning- Writing
Anxiety
Depression
Schizophrenia
Bipolar Disorder
Obsessive-Compulsive
PTSD
Anorexia/Bulimia
Substance Use
Other __________________

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Psychiatric History- continued:

2. Have you ever been psychiatrically hospitalized? □ yes □ no When? ___________ How long? ___________

3. Have you received counseling or therapy? □ yes □ no When? ___________ How long? ___________

Current Medical Condition

1. Describe your present health.

2. Are you presently on medication? □ yes □ no

Current Medications

Type Amount Frequency Duration of Treatment Reason

3. Have you been on medication in the last five (5) years? □ yes □ no
Medication History

Type Amount Frequency Duration of Treatment Reason

4. Are you allergic to any drugs? □ yes □ no Please specify:

5. How is your appetite?

Have you recently had any weight gain or weight loss? □ gained □ lost □ neither

Height: Weight:

6. How many hours do you typically sleep each night?

Is this adequate for you to function well? □ yes □ no Do you have difficulty sleeping? □ yes □ no
9. Do you wear glasses or contact lenses? □ yes □ no Last eye exam:

Are you: □ near-sighted □ far-sighted □ other

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Family Background

1. Spouse Information

Name

Occupation: Phone:

2. Do you have children? □ yes □ no

Highest Grade Difficulties in Learning or Other Disabilities
Names Ages
Completed (Describe)

3. Father's Information (pertains to your biological father)

Name: Home Phone:

Address: Work Phone:

Occupation: Educational Level:

Difficulties in learning? □ yes □ no Describe:

Other disabilities (e.g., physical, psychological)? Describe:

4. Mother's Information (pertains to your biological mother)

Name: Home Phone:

Address: Work Phone:

Occupation: Educational Level:

Difficulties in learning? □ yes □ no Describe:

Other disabilities (e.g., physical, psychological)? Describe:

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Family Background- continued:

5. Do you have sisters and brothers? □ yes □ no (add additional pages if needed)

Highest Grade Difficulties in Learning or Other Disabilities

Names Ages
Completed (Describe)

6. Other Significant Information About Your Family

Please indicate the existence of any of these conditions in your family. Indicate the relationship of the person to you
(e.g., father, maternal grandmother):

Mental Health Disorders □ yes □ no Who? What?

Intellectual Disability □ yes □ no Who? What?

Epilepsy □ yes □ no Who?

Other Neurological Disorder □ yes □ no Who? What?

Autism Spectrum Disorder □ yes □ no Who? What?

Serious Chronic Illness □ yes □ no Who? What?

Speech/Language Problems □ yes □ no Who? What?

Substance Abuse □ yes □ no Who? What?

Trouble with the Law □ yes □ no Who? What?

What languages are spoken in your home?

What language did you learn first?

At what age did you begin to learn English?

How often has your family moved?

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Educational Background- Elementary and Secondary School History

1. Did you attend public or private schools?

2. How many schools did you attend? Indicate when moves took place.

3. Did you repeat any grades in school? □ yes □ no Specify:

4. Did you tend to get in trouble frequently in school? □ yes □ no

What for:

5. Were you ever suspended or expelled from school? □ yes □ no

What for:

6. What things were hard for you in elementary school?

7. What things were hard for you in junior high and high school?

8. Did you or will you graduate high school? □ yes □ no Graduation date?

9. Did you earn a GED? □ yes □ no Graduation date?

10. High school grade point average?

11. Best S.A.T. scores (if taken): Verbal Math Was test: □ Standard Time □ Extended Time

12. Best A.C.T. scores (if taken): English______ Math________ Reading_______ Science_______ Composite_____

Was test taken with: □ Standard Time □ Extended Time

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Educational History- continued:

13. In high school, have you taken or are you currently taking?

Algebra? □ yes □ no # of semesters letter grade earned

English Composition? □ yes □ no # of semesters letter grade earned

Foreign Language? □ yes □ no # of semesters letter grade earned

Special Education Services or Tutoring

1. Did you receive any special education services in school? □ yes □ no Years

2. Did you have an IEP? □ yes □ no 504 plan? □ yes □ no Years

What category? (e.g. learning disability, other health impairment, etc) _____________________________________

3. Did you attend self-contained classes? □ yes □ no Years

4. Did you attend a school or program for students with special needs? □ yes □ no Years

Specify: ______________________________________________________________________________________

5. Did you attend any other types of academic support programs? □ yes □ no Years

Specify type, duration and dates of attendance:

6. Describe tutoring you have had (subjects, hours/week, when, and how long):

7. What help did you find the most beneficial and why?

9. Previous evaluations related to your learning difficulties (list chronologically)

Date Examiner Place of Evaluation Diagnosis

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College History

1. Colleges and/or Technical Schools Attended (indicate dates):

2. List Current Courses:

3. Have you taken any Learning Support classes (course numbers below 100)? □ yes □ no
If yes, which areas? □ Reading □ English □ Math

Have you passed them? □ yes □ no

4. In college, have you taken or are you currently taking?

Algebra? □ yes □ no # of semesters letter grade earned

English Composition? □ yes □ no # of semesters letter grade earned

Foreign Language? □ yes □ no # of semesters letter grade earned

8. What are your best subjects?

9. What are your poorest subjects?

10. Current Cumulative G.P.A.: Major:

11. Class Status: □ freshman □ sophomore □ junior □ senior □ graduate

12. Degree Program: □ Certificate □ Associates □ Bachelors □ Masters □ Doctorate/Professional

13. Anticipated Graduation Date:

14. What things are currently most difficult for you?

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Work History (list all salaried and volunteer positions beginning with the most recent)

Title Responsibilities Dates

1. Have you ever been, or are you currently involved in any legal difficulties? □ yes □ no

Specify:

2. Are you a veteran of the armed forces? □ yes □ no Dates of service:

Current Plans

Other individuals may have helped you complete this case history. However, you should complete this section in a frank,
complete and thoughtful manner. Please use your own words and handwriting.

1. What is your purpose in seeking this evaluation?

2. Describe how your learning problems affect your academic performance now.

3. What type of special services do you believe you will need in college and why?

4. Describe your strengths as you see them.

5. What do you enjoy doing in your spare time?

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Current Plans, continued

6. In what college activities do you currently or plan to participate (e.g., fraternity/sorority, intramural sports, student
government, intercollegiate sports)?

7. What are you interested in studying?

8. What do you plan to do after college?

9. Additional information:

I have provided complete, true and accurate information to the best of my knowledge. I understand that false or
inaccurate information may invalidate my evaluation.

Signed:
Applicant Date

8/21/2019

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