Process for AD/HD Assessment
1. The student is given the AD/HD Assessment Packet which includes:
· Adult Intake Questionnaire (AIQ)
· Parent retrospective Report (PRR)
· Parent/Childhood ADHD Rating Scale
· Adult rating Scale 2 (ARS 2)
s The AIQ, PRR and the Parent/Child ADHD Rating Scale must be completed before the first appointment is scheduled. The ARS 2 must be completed by someone who knows the student, i.e. roommate, significant other, best friend, etc..
2. Please make every attempt to bring in report cards from K-12. Copies are fine. All will be returned back to you. You may have to call your high school to get your records.
3. Also, bring in a couple examples of current schoolwork (term papers, test with scores etc..)
4. The initial appointment will be scheduled after the AD/HD Assessment Packet has been completed and returned to the Counseling Center.
5. At your appointment we will continue to screen for AD/HD with several diagnostic tools. These will include the Brown AD/HD Scales, and the Adult Rating Scale 1. There are times when the Conners’ Continuous Performance Test will also be suggested by your Counselor.
6. At the end of your Initial appointment, the Counselor will determine if further assessment is clinically indicated. 3-4 additional, consecutive weekly appointments will then be scheduled by the Counselor.
7. At the final appointment your Counselor will discuss the assessment findings and treatment options with you. Academic accommodations will also be discussed with you at this time if appropriate.
s If you miss a scheduled appointment and a waiting list exists, your name will be placed at the bottom of the waiting list (and the rest of your scheduled appointments will be canceled).
06/11 M. Anderson
ADULT INTAKE QUESTIONNAIRE
(For ADD/ADHD Assessment)
In order for us to be able to fully evaluate you, please fill out the following questionnaire to the best of your ability. We realize there may be information that you do not remember or have access to; do the best you can. Thank you!
PATIENT IDENTIFICATION
Name: ______Date: ______
Birthday: ______Age: ______Sex ______
Relationship Status: ______
Children: ______
Address: ______
City: ______State: ______Zip: ______
Home Phone #: ______Work #: ______
REFERRAL SOURCE
Referral Source: ______
Referral Address: ______Phone: ______
PURPOSE OF THE CONSULTATION
(Please give a brief summary of your main problems)
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WHY DID YOU SEEK THE EVALUATION AT THIS TIME?
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PRIOR ATTEMPTS TO CORRECT PROBLEMS/PRIOR PSYCHIATRIC HISTORY
(Please include with other professionals, medications, types of treatment, etc.)
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MEDICAL HISTORY
Current medical problems/medications: ______
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Past medical problems/medications: ______
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Other doctors/clinics seen regularly: ______
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Any history of head trauma? (describe): ______
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Ever had any seizures or seizure-like activity: ______
Any periods of spaciness or confusion? ______
Prior abnormal lab tests, X-rays, EEG, etc.: ______
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Allergies/drug intolerances (describe): ______
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CURRENT LIFE STRESSES
(Include anything that is currently stressful for you. Examples include relationship, job, school, finances, children, etc.) ______
FAMILY STRUCTURE/HISTORY
Family Structure (Who do you currently live with?):
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Significant Development Events (Including marriages, separations, divorces, death, traumatic event, losses, abuse, etc.) ______
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Current Relationship Situation: ______
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History of Past marriages or Significant Relationships: ______
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Were you adopted? ______
Please take the time to consult with your parents regarding their history and any known suspected mental health history for members of the extended family (those related by blood).
Natural Mother’s History- Age: ______Employed as: ______
School- highest grade completed: ______
Learning problems (specify): ______
Behavior problems (specify): ______
Marriages: ______
Medical problems: ______
Childhood atmosphere (family positions, abuse, illness, etc.): ______
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Has mother ever sought psychiatric treatment? Yes ______No ______
If yes, for what purpose? ______
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Mother’s alcohol/drug use history: ______
Have any of mother’s blood relatives ever had any learning problems or psychiatric problems; including such things as alcohol/drug, depression, anxiety, suicide attempts, psychiatric hospitalization, etc.? (specify): ______
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Natural Father’s History- Age: ______Employed as: ______
School- highest grade completed: ______
Learning problems (specify): ______
Behavior problems (specify): ______
Marriages: ______
Medical problems: ______
Childhood atmosphere (family positions, abuse, illness, etc.): ______
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Has father ever sought psychiatric treatment? Yes ______No ______
If yes, for what purpose? ______
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Father’s alcohol/drug use history: ______
Have any of mother’s blood relatives ever had any learning problems or psychiatric problems; including such things as alcohol/drug, depression, anxiety, suicide attempts, psychiatric hospitalization, etc.? (specify): ______
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Siblings (name, ages, problems, strengths, relationship to patient)
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Children (names, ages, problems, strengths): ______
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EDUCATIONAL HISTORY
Last grade complete: ______Last school attended: ______
Average grades received: ______
Any academic problems: ______
Learning strengths: ______
Any behavior problems in school? ______
In general, what would your teacher have said about you? ______
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EMPLOYMENT HISTORY
(summarize jobs you’ve had, list most favorite and least favorite)
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Any work-related problems? ______
What would your employers or supervisors have said about you? ______
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Military History: ______
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Any Legal Problems? ______
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ALCOHOL AND DRUG HISTORY
Please list age started and types of substances used through the years and any current usage. Also, describe how each of the substances made you feel; what benefit you got from them. These include alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc), cocaine or crack, amphetamines, crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms), PCP, etc. (list these on the next page)
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Ever experience withdrawal symptoms from alcohol or drugs? ______
Has anyone ever told you they thought you had a problem with alcohol or drugs? ______
Have you ever felt guilty about your drug or alcohol use? ______
Have you ever felt annoyed when someone talked to you about your drug or alcohol use? ____
Have you ever used drugs or alcohol first thing in the morning? ______
Caffeine use per day (caffeine is in coffee, tea, sodas, chocolate, etc.) ______
Circle symptoms that apply to you: Restlessness, nervousness, excitability, insomnia, flushed face, frequent urination, upset stomach, muscle twitching, rambling thoughts or speech, heart pounding or racing, easily fatigued, irritability
Nicotine use per day, past and present (nicotine is in cigarettes, cigars, tobacco chew, etc.) ____
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Cultural/Ethic Background ______
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Describe your relationships with friends ______
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Describe yourself ______
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What are your goals in seeking this consultation? What do you hope to gain?
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PARENT RETROSPECTIVE REPORT
Client Name: ______Date: ______
Completed by: Mother _____ Father _____ Other _____ Relationship: ______
INSTRUCTIONS: Your son/daughter is requesting an evaluation at this clinic. As part of the evaluation, we are requesting an evaluation at this clinic. As part of the evaluation, we are requesting that you complete this questionnaire as best you can. The information you provide is very important in our efforts, and your cooperation is appreciated.
INFANCY
Were any of the following problems present during your child’s first few years of life:
(Circle one answer for each question)
Did not enjoy cuddling Yes No
Difficult to comfort Yes No
Colic Yes No
Excessive restlessness Yes No
Excessive irritability Yes No
Excessive crying Yes No
Excessive shyness Yes No
Did your child seem to develop more slowly than other children in the following areas: (Circle one answer for each question)
Walking Yes No
Talking Yes No
Riding a bike Yes No
Learning to skip Yes No
Learning to throw or catch Yes No
Birth weight: ______
Did your child have a difficult or premature birth? ______
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TEMPERAMENT/MOOD
Please rate the following behaviors of your child up to 5 years of age.
Activity level – How active was your child from an early age? ______
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Distractibility – How well did your child pay attention? ______
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Play – How well was your child able to play alone without constantly needing your attention?
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Adaptability – How well did your child deal with transition and change? ______
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Mood – What was your child’s basic mood? ______
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Did your child, as a youngster or teen, at any time, display/experience severe mood shifts or seem significantly depressed, irritable, violent, or super-energized? Please describe in detail.
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Are there any members of your extended family, related by blood, (including past generations) who have been diagnosed with, or suspected of having: ADHD/ADD, Learning Disabilities, Bipolar Disorder (manic-depression), Depression, Anxiety, Schizophrenia, Obsessive Compulsive Disorder, Asperger’s Syndrome, or Tourette’s (or anyone who has attempted/completed suicide, any hospitalization for mental issues, extremely moody, really high energy all the time?) ______
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Did you ever notice that your child would talk too much or too loudly, or would talk quickly, shifting from topic to topic and not be able to be redirected? Please describe the intensity and how often it would occur. ______
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Did your child engage in dangerous or risky behavior, often make poor judgments, or act impulsively? Please describe. ______
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Did your child ever experience visual or auditory hallucinations, severe thought distortion, or tyrannical behavior? Was your child oppositional? ______
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Would your child become more active in the evening; becoming troublesome or having ‘fits’? Did your child have nightmares or night terrors, trouble sleeping, insomnia? How was your child in the morning upon waking? Please describe. ______
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Did your child seem more ‘cruel’ than other children or have more trouble than other children in understanding the feelings of others? ______
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SCHOOL HISTORY
Please indicate whether your child had any of the following school experience (circle one answer for each question).
Was retained a grade in school Yes No
Difficulty with reading Yes No
Difficulty with math Yes No
Received poor grades Yes No
Disliked doing homework Yes No
Disliked going to school Yes No
Had behavior problems in school Yes No
Was tested for special education Yes No
If yes to any of the above, please describe the problems. ______
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PROFESSIONALS CONSULTED
Did you consult with any clinician for any concerns you may have had about your child’s behavior or school progress? Yes No
If yes, please describe your child’s problems you sought help for.
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PARENT CHILDHOOD ADHD RATING SCALE
Patient’s Name: ______Date: ______
Parent’s Name: ______
Circle the number in the one column which best describes your son/daughter as a child (ages 5 to 12).
Not at all / Just a Little / Pretty Much / Very Much1. / Often failed to give close attention to details or made careless mistakes / 0 / 1 / 2 / 3
2. / Had difficulty sustaining attention in tasks or activities / 0 / 1 / 2 / 3
3. / Often did not seem to listen / 0 / 1 / 2 / 3
4. / Did not follow through in instructions and failed to finish school work and chores / 0 / 1 / 2 / 3
5. / Often had difficulty organizing tasks and activities / 0 / 1 / 2 / 3
6. / Often avoided or disliked doing schoolwork or homework / 0 / 1 / 2 / 3
7. / Often lost or misplaced things (i.e. toys, school assignments, books, pencils, etc.) / 0 / 1 / 2 / 3
8. / Was easily distracted / 0 / 1 / 2 / 3
9. / Was often forgetful / 0 / 1 / 2 / 3
10. / Was often fidgety or squirming in seat / 0 / 1 / 2 / 3
11. / Had difficulty remaining seated / 0 / 1 / 2 / 3
12. / Often ran about and climbed excessively in inappropriate situations / 0 / 1 / 2 / 3
13. / Often had difficult playing quietly / 0 / 1 / 2 / 3
14. / Often “on the go” or acted if driven by a motor / 0 / 1 / 2 / 3
15. / Often talked excessively / 0 / 1 / 2 / 3
16. / Often blurted out answers before questions had been completed / 0 / 1 / 2 / 3
17. / Had difficulty awaiting turn / 0 / 1 / 2 / 3
18. / Often interrupted or intruded on others (i.e. butted into conversations or games) / 0 / 1 / 2 / 3
ADULT RATING SCALE 2
Your name: ______Date: ______
Name of individual under evaluation: ______
Relationship to this individual: Parent Spouse Employer Friend Other ______
Below is a list of behaviors or problems that some people have. To the right of each item indicate, in your opinion, how much of a problem each one is for the individual under evaluation. Please be sure to provide an answer to each question.
Not at all / Just a little / Pretty Much / Very Much1. Physical restlessness, excessive fidgeting
2. Difficulty concentrating
3. Easily distracted
4. Impatient
5. “Hot” or explosive temper
6. Unpredictable behavior
7. Shifts often from on uncompleted task to another
8. Difficulty completing tasks
9. Impulsive
10. Talks excessively
11. Often interrupts others
12. Often loses things
13. Forgets to do things
14. Engages in physically daring activities, reckless
15. Always on the go, difficulty sitting still
16. Does not appear to listen to others when spoken to
17. Difficulty sustaining attention
18. Difficulty doing things alone
19. Frequently gets into trouble with the law
20. Difficulty delaying gratification
21. Lack of organization skills
22. Inconsistent work/school performance
23. Inability to establish and maintain a routine
24. Performing below level of competence in work/school
25. Overexcitability
Lisa L. Weyandt, Ph.D., Central Washington University, Ellensburg, WA 98926 (509) 963-2381 Ext 3688