ADHD Neuropsychology Extra Intake Information

ADHD Neuropsych Extra Intake Information - Practitioner Use

ADHD Neuropsych Extra Intake Information - Practitioner Use

ADHD Neuropsych Extra Intake Information - Practitioner Use

Client Name
Client Name
First
Last

Diagnosis

Reason for Referral

Developmental History

Hyperactivity Symptoms

Check when client was younger and current concerns with the following (Needs to meet at least 6 symptoms)

Inattentive Symptoms

Check when client was younger and current concerns with the following (Needs to meet at least 6 symptoms)

Impulsivity

Medical History / Medications

Substance Use History

Sensory Deficits and Hypersensitivities

Significant Trauma History

Educational History / Learning Difficulties

Other Mental Health Conditions

Family History

Current Supports

Current Hobbies / Interests

Assessment Completed By