CONFIDENTIAL TESTING

PERSONAL INFORMATION

Today’s Date ______

1.Name: ______

Last First Middle

2.MailingAddress: ______

City: ______State: ______Zip: ______

3.Phones: Cell:______Work: ______E-mail______

4. If we need to contact you, where would you prefer we leave a message? □Work □Cell □E-mail

5.Birthdate: ______Age: _____

6. Gender: ______

7.Sexual Orientation: ______

8.Are you currently attending school? □Yes □No

9.If Yes; Major(s)/field(s) of study ______

10.University Status

□Enrolled full-time □Enrolled part-time □Other ______

□First year / freshman □Sophomore □Junior □Senior □Graduate / professional

______GPA (Cumulative)______GPA (prior semester)

11.Who has referred you for testing? ______

12.Please indicate the reason(s) you were referred for testing: ______

______

______

______

13.Does your reason for inquiring about testing include concerns about any of the following?Please check all that apply.

□Learning Disability□Impulsivity/ hyperactivity□Reading speed

□Spelling□Pronouncing new words □Understanding what you read

□Math calculations □Math reasoning □Story problems

□Grammar / punctuation □Study skills □Listening

□Memory problems □Depression □Expressing thoughts in writing

□Head injury □Drugs / alcohol□Attention/Concentration Problems

□Anger □Anxiety□Social interactions/relationships

14.Is English your first and primary language? □Yes □No If “No” please explain:

______

15.Were any other languages spoken in your home as a child? □Yes □No If “Yes” please explain:

______

16.Race / Ethnicity

□African American / Black / African□Asian American

□American Indian or Alaska Native□Arab American / Arab / Persian

□Asian American / Asian□Native Hawaiian or Pacific Islander

□East Indian□Caucasian / White / European American

□Hispanic / Latino / Latina□Multi-racial

□Other (please specify) ______

17.Have you served in any branch of the military (active duty, veteran, National Guard or reserves)? □Yes □No

18.Did your military experiences include any traumatic or highly stressful experiences which continue to bother you?

□Yes □No

19.Have you undergone academic or psychology testing? □Yes □No

□Attention Deficit / Hyperactivity Disorders□Neurological disorders

□Deaf or hard of hearing□Physical / health related disorders

□Learning disorders□Psychological disorder / condition

□Mobility impairments□Other

If yes, what was the diagnostic outcome?______

20.What medications (if any) are you taking specifically for a mental health condition? ______

______

21.Are you currently taking any other medications? □Yes □No Name of medication(s):______

22.Who would you like us to contact in case of any emergency? Name: ______

Relationship to you: ______Phone: ______

23. Is there any other information that would be important for us to know?

______

Testing Intake Questionnaire

  1. Briefly describe the problem(s):
  1. Describe how the problem affects academic/work/social functioning:
  1. How long has this problem been as it is now, and when didyou first notice it?

Educational History

  1. How have you done academically in the recent past?
  1. What were your strengths and weaknesses in high school?
  1. Were you ever in any special classes or did you have tutoring or other assistance? □Yes □No
  2. Were you ever tested for any type of disability (in high school or before)? □Yes □No
  1. Describe your academic progress in elementary, middle or high school:
  1. What activities were you involved with in middle or high school?
  1. How would you describe your social activity in high school (dating, clubs, cultural or ethnic factors, etc.)?

Family History

  1. Does anyone in your immediate or extended biological family have the same or a similar problem?
  1. Describe the current occupations of your parent(s) (or primary guardian) and their educational backgrounds.
  1. Are you aware of any developmental problems you experienced (slow in learning to walk, talk, etc.)?
  1. Do you know if your mother had any difficulty with you during pregnancy or childbirth?

Medical History

  1. Are you currently taking any medications? □Yes □No If yes, please list:
  1. Are you currently or previously using any controlled substances? □Yes □No If yes, please describe:
  1. Do you drink alcohol? □Yes □No If yes, please estimate weekly average number of drinks: ______
  1. Describe any serious illnesses or injuries you have experienced? Include any high fevers, periods of unconsciousness, or closed head injuries.
  1. What types of physical activity do you engage in?
  1. Do you have any problems with coordination, or any other physical impairment?

Specific Educational Problems

  1. Reading/Writing
  1. Do you have to reread material several times before you understand it? □Yes □No
  2. Do you have trouble picking out important ideas? □Yes □No
  3. Do you have trouble remembering what you read? □Yes □No
  4. Do you move your lips or say the words to yourself when you read? □Yes □No
  5. Do you read all materials at the same speed? □Yes □No
  6. Do you have difficulty with unfamiliar words? □Yes □No
  7. Do you read too slowly? □Yes □No
  8. Are you easily interrupted by noise when you read? □Yes □No
  9. Do you frequently lose your place while reading? □Yes □No
  10. Do you have trouble with spelling? □Yes □No
  11. Do you reverse letters or words? □Yes □No
  1. How is your grammar? ______
  1. Math
  1. What problems do you have with math?
  2. Can you work story problems? □Yes □No
  3. Do you reverse numbers (for example, read 123 as 213)? □Yes □No
  4. Can you do math operations in your head (add, subtract, multiply, divide)? □Yes □No
  1. What level of math have you completed (high school or college)? ______
  1. Auditory Processing
  1. Do you have trouble listening and taking notes? □Yes □No
  2. Do you have trouble picking out the main ideas in lectures? □Yes □No
  3. When you study, do you need quiet? □Yes □No
  4. Do you need to frequently move around when studying? □Yes □No
  5. Does movement distract you when studying, taking a test, or listening in class? □Yes □No
  6. Do you do better if you hear the directions, read the directions, or if someone shows you how to do a complicated task? □Hear directions □Read directions □Shown how to do a complicated task
  7. Do you hear buzzing or ringing in your ears? □Yes □No
  8. Do you find that peoples’ voices are too loud or too soft for you? □Too loud □Too soft □Neither

Miscellaneous

  1. Do you have problems with right/ left orientation? □Yes □No
  2. Do you have problems remembering or following directions to get somewhere? □Yes □No
  3. Do you have problems with spatial orientations? □Yes □No
  4. Do you have problems with test anxiety? If yes, please describe. □Yes □No
  1. What techniques have you developed to compensate for any of the special learning problems you noted above?

1