Student Intake Form

Student's First Name:

Student's Last Name:

Date of Birth:

Age:

Parent/Guardian:

Phone:

Email:

Address:

City:

State:

Zip:

Occupation of Mother/Father:

Family History of Attention/Learning Problems:

Reason for Consultation:

Have you tried other interventions, such as tutoring, or other help?
YesNo

Have you been diagnosed for by a Doctor for any of the following?:
ADHD/ADDAsperger'sPDDAutismLearning DisabilitiesDyslexiaNVLDAuditory Processing Disorder

Medications:

Mg:

Daily Times:

Birth Complications:

Premature:
YesNo

Allergies:

Dietary Concerns:

Supplements:

Health Issues:

Sleep Difficulties:
YesNo

Social Skills: (If any difficulties, please list/explain)

Check off any difficulties you are experiencing:
Reading with fluencyReading comprehensionHandwriting legibilityWriting assignmentsSpellingMathSensitivity to clothingSeams to socksTouching othersBeing touchedSensitivity to soundsTrouble with changeGetting ready in the morningOrganizational skillsCompleting homeworkDislike schoolBehavioralImmature for agePoor memoryDifficulty understandingFollowing directionsRambling/getting to the point when talkingEye contactImpulsive actorSlow learnerSays words out loud when reading/talks out-loud to self to complete tasksPoor balanceStudent has an IEPStudent has a 504 plan

Attention Screening

InattentionOften does not give close attention to details/makes careless mistakes in schoolwork or other activities.Often has trouble keeping attention on tasks or play activities.Often does not seem to listen when spoken to directly.Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (loses focus, gets sidetracked).Often has trouble organizing activities.Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).Often loses things needed for tasks and activities (toys, school assignments, pencils, books, or tools).Is often easily distracted.Is often forgetful in daily activities.Hyperactivity and Impulsivity six or more of the following symptoms of hyperactivity-impulsivityOften fidgets with hands or feet or squirms in seat when sitting still in expected.Often or excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).Often has trouble playing or doing leisure activities quietly.Is often “on the go” or often acts as if “driven by a motor”.Often talks excessively.Often blurts out answers before questions have been finished.Often has trouble waiting one’s turn.Often interrupts or intrudes on others (e.g., butts into conversations or games).