Re:outpatient psychological evaluation
Dear Parent:
Thank you for your interest in Glenwood’s outpatient services. Before we can schedule your child for a psychological evaluation we need to have all information completed and sent back. Once all information is sent back we will phone you to let your know your child has been put on the waiting list. Our current waiting list is around six months from the time your paperwork is received back in our office. Below you will find a checklist of required documents. Please make sure you have checked off the list so that all information has been gathered and completed before sending in. Questionnairesneed to be completed and required documents attached so that we will be able to get your child on the waiting list.
As part of our evaluation process, we require that the individualsunder the age of five receive a formal hearing evaluation prior to their scheduled evaluationat Glenwood. We encourage you to pursue this hearing evaluation as soon as possible. You can contact your Family Practitioner to discuss your options or contact one of the clinics on the attached list to discuss evaluation options at their site. If your pediatrician is willing to fax your records regarding hearing; showing there are no concerns then no formal healing evaluation is required. Additionally, we ask that you gather copies of any previous testing reports (e.g., psychological, speech, occupational therapy, educational, early intervention), as well as any current IEPs and/or other information you have and send in with your registration so that this material can be reviewed prior to your scheduled evaluation. Please feel free to contact me with any questions at 205-795-3203. Fax number is 205-795-3290.
______Completed Parent History Packet (attached form)
______Copy of insurance card (front and back)
______Copy of any guardianship, custody, divorce/ visitation agreements
For an evaluation in Birmingham office, please mail completed forms to:
Anna Walchli
c/o Intake
150 Glenwood Lane
Birmingham, AL 35242
Fax# 205-795-3290
For an evaluation in the Huntsville office, please mail completed forms to:
Beth McKay
c/o Intake
4092 South Memorial Parkway, Ste 102
Huntsville, AL 35802
****Please do not fold paperwork if mailing it back.
UAB Civitan-Sparks Clinic
Audiology Clinic
University of Alabama at Birmingham
1530 3rd Ave South
CH19 307
Birmingham, AL 35294-2041
Phone: 205-934-5471
1-800-822-2472 -option 8
UA Speech and Hearing Center
University of Alabama
700 University Boulevard East
Tuscaloosa, AL 35401
Phone: 205-348-7131
USA Speech and Hearing Clinic
University of South Alabama
1119 HAHN
5721 USA Drive North
Mobile, AL 36688-0002
Phone: 251-445-9378
AUM Speech and Hearing Clinic
Auburn University at Montgomery
Liberal Arts Building, Room110
7041 Senators Drive
Montgomery, Alabama 36117
Phone: 334-244-3408
AU Speech and Hearing Clinic
Auburn University
1199 Haley Center
Auburn, AL 36849
Phone: 334-844-9600
Hearing and Speech Clinic
303 Williams Ave SW
Huntsville, AL 35801
Phone:256-536-7405
Hearing Associates of Dothan, LLC
Dothan Office:
1891 Honeysuckle Road
Dothan, AL 36305
Phone: 334-702-4327
Enterprise Office:
101 Brunson St., Suite 102
Enterprise, AL 36330
Phone: 334-308-9368
Meridian Speech and Hearing Center
2203 Hwy 39 N Suite A, Box 5
Meridian , MS - 39301
Phone: 601-483-8121
DIAGNOSTIC TESTING/TREATMENT INFORAMTION
Please complete this form in full
Please provide information regarding any or ALL previous or PENDING evaluations or treatment
Copies of evaluation(s) must be sent back with the intake packet.
______School EvaluationProvider?______Date:______
______Speech/HearingProvider?______Date:______
______NeurologicalProvider?______Date:______
(EEG, CT, MRI)
______PsychiatricProvider?______Date:______
______Psychological/Provider?______Date:______
Counseling
______Occupational TherapyProvider?______Date:______
______Physical TherapyProvider?______Date:______
______DevelopmentalProvider?______Date:______
______GeneticProvider?______Date:______
______OtherProvider?______Date:______
Previous/Current Diagnoses (please check all that apply)
______Developmental DelayProvider?______Date:______
______Autism SpectrumProvider?______Date:______
(PDD-NOS, Asperger’s)
______NeurologicalProvider?______Date:______
______Speech Language DelayProvider?______Date:______
______Intellectual Disability/Provider?______Date:______
Mental Retardation
______Social DelaysProvider?______Date:______
______Learning DisorderProvider?______Date:______
______Reading______Math ______Written Expression ______Oral Expression
______ADHD/ADDProvider?______Date:______
______Tic DisorderProvider?______Date:______
______Oppositional DefiantProvider?______Date:______
Disorder
______Anxiety Disorder/OCDProvider?______Date:______
______DepressionProvider?______Date:______
______Bipolar DisorderProvider?______Date:______
______PsychosisProvider?______Date:______
Is or has your child currently receiving any of the following?
______Psychiatric Medications______Counseling
______Speech Therapy______Occupational Therapy
______Physical Therapy______Other type of therapy
If yes, please list names of those who provided service and dates services received.
______
______
______
If child is currently receiving Early Intervention Services or enrolled in public and/or private school, please provide the following information:
Under what special education exceptionality is the child receiving services?
______Autism______Developmental Delay
______Intellectual Disability______Emotional Disability
______Multiple Disabilities______Orthopedic Impairment
______Other Health Impairment______Specific Learning Disability
______Speech or Language Impairment______Traumatic Brain Injury
______Visual Impairment______Hearing Impairment
What services is the child receiving related to his/her exceptionality?______
______
______
______
**Please attach ALL diagnostic reports with this packet. This will also include the child’s most current IEP or IFSP.**
Parent/Guardian Questionnaire
Glenwood Inc.
Date: ______Form completed by: ______Relationship to client: ______
Family Data
Client’s Name: ______Birthdate: ______Age: ______
Gender: Male ______Female ______Ethnicity: ______SS# ______Home # ______
Home Address (street, city, zip):______
Father’s Name: ______DOB: ______Education: ______
Employment: ______Business Phone: ______
Father’s email (optional): ______
Mother’s Name: ______DOB: ______Education: ______
Employment: ______Business Phone: ______
Mother’s email (optional): ______County: ______
Best # to contact you:______Name child goes by: ______
Parents are: Married ____ Divorced ____ Separated _____ Widowed _____ Single/Never Married ______
Date ______Date ______Date ______Date ______Other (explain): ______
Client’s legal guardian: Both Birth Parents ____ Birth Mother _____ Birth Father ____ Adoptive Parents ____
Department of Human Resources ____ Legal Guardian _____
Client lives with: Both Parents ______Mother ______Father ______Other ______
List the names and ages of all siblings (step/ half siblings also):
NameAgeRelationship (step/half) Current Grade Learning/ Medical Problems
______
______
______
______
Please list all individuals, and their relationship to the child, including parents who are currently living in the home:
______
______
Is this a Foster Home Placement? Yes _____ No ____ Adopted: Yes ____ No _____
Age at placement: ______Age at adoption: ______
Other important/ influential people frequently in client’s life (who do not reside in the home): ______
Are there any current custody issues? Yes ______No ______
If Yes, please explain:______
If applicable, what are the custody or visitation agreements? ______
______
Has the Department of Human Resources (DHR) ever been involved with this client? Yes ______No ______
Dates of DHR involvement: ______
Reasons for DHR involvement: ______
______
Do all parties involved in the care of the child agree on the need for an evaluation of this child? ______
______
Who referred you to Glenwood Outpatient Services ? ______
Phone number: ______Why were you referred? ______
Chief problems as you see them: / When did the problems begin? (age or date)1.
2.
3.
4.
5.
Has his/her hearing been tested? Yes ______No ______
If yes, who tested? ______when tested? ______
What were the results? ______
Describe his/her response to sound (e.g., responds to all sounds, responds to loud sounds only, extremely sensitive to loud noises, etc.) ______
Has his/her vision been tested? Yes ______No ______
If yes, who tested? ______when tested? ______
What were the results? ______
Does he/she have difficulty walking, running, or participating in other activities that require small or large muscle coordination? Yes _____ No ______
If yes, please describe: ______
Pregnancy History - Mother
While you were pregnant were you under a doctor’s care? Yes ______No ______
Mother’s age at time of birth ______Length of pregnancy ______
Miscarriages ______
During this pregnancy did you have:
Condition / Yes / No / DescribeAnemia
Elevated Blood Pressure
Toxemia/ Eclampsia
Swollen Ankles
Gestational Diabetes
Placenta Previa
Bleeding
Measles
German Measles
Flu
Other Virus
Vomiting
Injury
Medication during pregnancy (prescription and over-the-counter)
Emotional Problems
Threatened miscarriage or early contractions
Alcohol, drugs, tobacco use / Specify:
Other?
Birth History
Were you given medication? Yes _____ No ______What kind? ______
Did you have natural childbirth? Yes _____ No ______
Was labor induced? Yes _____ No _____ Was induced labor planned? Yes _____ No _____
Type of delivery: Head first ______Feet first _____Caesarian ______
Was the delivery unusual in any way or any complications? Yes _____ (How? ______) No _____
Did you have twins? Yes _____ No_____ Which born first? ______
Did this baby have: Breathing problems? Yes _____ No _____ Don’t know _____
If yes was oxygen used? Yes _____ No _____
Cord around neck? Yes _____ No _____ Don’t know _____
Did this baby cry quickly? Yes _____ No _____ Don’t know _____
Was this baby’s color normal? Yes _____ No _____ Blue? _____ Yellow? _____ Don’t know _____
Was the baby premature? Yes _____ No _____ How much? ______
What did the baby weigh? ______Apgar Scores? ______
Was baby in Incubator? Yes ______No ______Neonatal Intensive Care? Yes ______No ______
Did you take the baby home with you from the hospital? Yes ______No ______How long after? ______
Was the baby normally active? Yes ______No ______Describe: ______
Problems noted at birth or shortly after: ______
______
Feeding
Did your child have problems with feeding as an infant? Yes ______No ______Describe: ______
Colic? _____ Vomiting? _____ Sucking Problems? _____ Swallowing Problems? _____ Chewing Problems? ____
Current weight: ______Any growth problems/concerns? Yes ______No ______
Is client on a special diet? Does he/ she take any nutritional supplements? If yes, please describe: ______
______
Is client a picky eater? If so, what foods will he/ she eat? ______
Describe his/her appetite and eating habits at present: ______
______
______
Development : Indicate age at which he/she began performing these behaviors
Sat unsupported: ______Crawl: _____ Stood alone: _____ Walked: _____ First words: _____
2-Word Phrases: ______First short sentences: ______Bladder trained: ______Bowel trained: ______
Out of diapers: ______
Your child’s overall development compared to others his age:
______Below Average______Average______Above Average
Were you ever concerned regarding any area of his/her development? _____ If yes, how old was he/she when you first became concerned? ______What were your concerns?______
Did a regression of skills or a loss of skills ever occur in the client’s development? Yes _____ No ______
If yes, when did this regression/ loss of skills occur? ______
If yes, please describe the regression/ loss of skills. ______
______
He/She communicates by which of the following (Check all that apply):
Crying ______Playful sounds ______Pointing with index finger ______Words _____
Phrases ______Sentences ______Sign Language ______Picture Communication ______
How much of his/her speech is understandable to you?Some _____Most _____All ______
How much of his/her speech is understandable to others? Some _____Most _____All ______
Does he/she have any problems understanding what someone says? Yes ______No______
FAMILY HISTORY
Has SOMEONE IN THE CLIENT’S FAMILY (immediate household or extended family) had problems with any of the following:
SPECIFY, if appropriate / PERSON’S RELATION TO CHILD (e.g., cousin, aunt, brother) / WHICH SIDE OF THE FAMILY? (Mother’s side/ father’s side?)Learning Problems / Specify:
Mental Retardation or Intellectual Disability
Developmental Delay or Disability / Specify:
Speech/ Language Problems
Genetic Condition (e.g., Down’s Syndrome, Fragile X) / Specify:
Other conditions (e.g., Cerebral Palsy, Fetal Alcohol Syndrome) / Specify:
ADHD or ADD
Autism Spectrum Disorder/ PDD
Tics or Involuntary Movements
Depression
Excessive Anxiety/Worry/Fears
Obsessive-Compulsive Disorder
Mania/ Bipolar
Psychosis/Schizophrenia (e.g., sees or hears things not there, has unusual thoughts)
Trouble with Law
Alcohol/drug abuse
Behavior problems as a child
Seizure Disorder
Chronic Illness
Medical History of Client
Has client had: / Yes / No / When / Describe (provide age)German Measles
Chicken Pox
Whooping Cough/Croup
Frequent Ear Infections
Allergy (food/ environment/ medication)
Convulsions/ Seizures (spells)
Injuries to head
Tonsillitis
Headaches or Dizziness
Lead Poisoning
Asthma
Other injuries
Other illnesses
Hospitalizations
Operations
Does he/she have a specific medical diagnosis? Or a significant health problem? ______
______
Describe client’s sleeping pattern now. Are there nightmares or night terrors now or in the past?
______
______
______
Physician Information
When did the client last have a physical examination? ______
Name of Pediatrician or Physician: ______
Address: ______
Current medicationsPrescriberDoseReason for Medication
______
______
Past medicationsPrescriberDoseReason for MedicationWhen/Why stopped?
______
______
BEHAVIOR/SOCIAL HISTORY OF CHILD/INDIVIDUAL
Has client experienced: / Yes / No / Specify or Describe:Abuse (physical, verbal, or sexual)
Neglect
Parent Divorce
Witnessed Domestic Violence
Experienced Death of Close Relative or Friend
Has Parent, Sibling, or other close relative with severe medical problems
Had Traumatic Experience
Excessive Shyness
Excessive Worries/ Fears
Overactivity
Trouble Paying Attention
Trouble with the Law
Violence towards others, including physical fights
Depression
Suicidal Thoughts or Attempts
Alcohol/Drug Use
Trouble Making Friends
Frequently Bullied by Others
Bullies Others
Aggression towards self or others
Is she/he currently in counseling? ______If so, what is the focus of treatment?______
Has she/he ever been in therapy? ______If so, when?______
What was the focus of treatment? ______
Has he/she ever been hospitalized or placed in residential treatment for mental health or behavioral problems?
If yes, when? ______For how long?______Where?______
Reasons/ Recommendations: ______
______
Does he/she have outbursts or “meltdowns” due to anger, frustration, and or/ sensory overload? If so, are there strategies that you have used that are helpful in correcting his behavior? ______
______
What does he/she do if told no? ______
What does the client enjoy doing in his/ her free time? ______
______
How does he/she get along with other children in the family? ______
______
How does he/she get along with children/loved ones not in the family? A leader? Follower? Playing with children who are older? Younger? ______
______
______
What is the age and sex of your child’s favorite playmate/ friend? ______
Describe your child’s mood and activity level: ______
______
______
Describe how he/she behaves in public (stores, restaurants, movies, etc…): ______
______
______
Educational Information
School attending: ______Teacher: ______
Child’s present grade: ______Has s/he repeated a grade? Which one and why?______
Current placement in school: Regular classroom _____ Special Education classroom (explain) ______
Resource room _____ Alternative school _____Home school_____ other (explain) ______
Has he/she been suspended this school year? Yes _____ No ______
If yes, why? ______
Have there been many changes in his/her school setting? ______If yes, please explain: ______
______
Has client attended Nursery School? ______Pre-kindergarten? ______Kindergarten? ______
Is the client currently in Daycare? ______Yes______No If Yes, where?______
Has the client been evaluated by the school? ______Yes______No
On average, what are his/her grades this year? ______
In what classes does he/she do well? ______
In what classes does he/she struggle? ______
Has there been any big changes in his/her grades (for example, s/he was passing, now failing)? ______
If yes, describe (When did it start? What classes?):______
Does he/she enjoy and feel successful in school? ______Please explain: ______
______
Has the teacher told you that he/she is having difficulty? ______
If yes, is the problem related to learning or behavior? ______
Please describe teacher’s concerns: ______
______
Did teachers in earlier grades have the same concerns? ______Did they also have other concerns?______
If yes, please describe: ______
______
Has/does your child receive tutoring? ______
______
What do you see as his/her strengths? ______
______
Comments: (Please use other side if necessary): ______
______
______
______
Parent or Guardian signature DateParent or Guardian signature Date