Only fill out if you would like me to have this information prior to our first session.
When did the problem start? Chronic or episodic? How does the problem present at home? At school/work? Where does the problem not occur?
Previous testing, counseling, tutoring, etc. Issues/diagnoses/doctors/psychiatrists/psychologists
Immediate family, extended family, learning disabilities, reading problems, mood or emotional difficulties, etc.
Schools attended, past and present teacher concerns, problems/successes in school, past and present support services, history of IEP or 504 Plan
Has anything of a traumatic nature happened? Accidents? Abuse? Bullying?
Worries, fears, concerns that affect willingness to complete normal or routine activities, recent changes in interests, appetite, sleep patterns, levels of irritability