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.

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?):

______

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.): ______

______

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): ______

______

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.): ______

______

Has father ever sought psychiatric treatment? Yes ______No ______

If yes, for what purpose? ______

______

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? ______

______

______

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? ______

______

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 Much
1. / 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 Much
1.  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