Psychology Testing Intake Form Parent/Guardian First Name:* Parent/Guardian Last Name:* Phone Number:*Email Address:* Child’s Full Name: First Middle Last The First Few Months of LifeAnything of note? How was feeding?Sleep patterns or problems:Personality:Milestones: At What Age Did Your Child Do Each of These?Sat without support:Crawled:Walked without holding on:Helped when being dressed:Tied shoelaces:Buttoned buttons:Ate with a fork:Stayed dry all day:Didn’t soil his or her pants:Stayed dry all night: Speech/Language DevelopmentAge when child said first word understandable to a stranger: Age when child said first sentence understandable to a stranger: Age when child first babbled: Any speech, hearing, or language difficulties? Does your child seem to understand what you say?Current daycare/preschool/school (if applicable): Why are you seeking assessment for your child/adolescent at this time?What are your top 3 concerns?Child CharacteristicsReview this checklist which contains concerns as well as positive traits that apply to children and adolescents, and mark any items that describe your child/adolescent. Feel free to add any others at the end under “Any other characteristics.” Affectionate Communication Clumsy, uncoordinated Developmental delays Distractibility – easily distracted by sights and sounds, easily sidetracked Eating – difficult to feed, picky eater Eye contact – difficult to catch his/her eye Fussy, difficult to soothe Gestures – uses and understands Happy, easy-going Learning difficulties Overactive – wiggles, squirms, won’t sit still Persistent – keeps trying when things are difficult Repetitive behavior Responds to sounds and when name is called Routine – likes to keep to a routine Sad Sleeping – difficult to put down, wakes frequently Social – enjoys being around people Tantrum frequently Underactive – tends to stay in the same place Any other characteristics?Please look back over the concerns you have checked off and choose the one that you most want your child to be helped with: Is there a family history of any developmental, learning or mental health challenges? Please explain:Special Skills or Talents of ChildList hobbies, sports, recreational, musical, TV, and toy preferences:Is there anything else we should know that doesn’t appear on this or other forms, but that is or might be important in working with your child?