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Adult Intake Form
The purpose of this questionnaire is to gather information about your history and present situation so that we may provide the most appropriate clinical services for you. Please answer each question as honestly and accurately as possible.
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* Indicates required question
Email
*
Your email
Name of person completing this questionnaire, if not the patient
Your answer
Relationship to patient
Your answer
Patient's Full Name
*
Your answer
Preferred Name
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Birth Gender, if different
Male
Female
Clear selection
Pronouns
*
He/Him
She/Her
They/Them
Primary Phone Number
*
Your answer
Street Address
*
Your answer
City or Town
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Marital Status
*
Married
Single
Prefer Not to Say
Race
*
Caucasian
African-American
Latino
Asian
Other:
Country of Birth
*
Your answer
Primary Language
*
English
Other:
Are you bilingual or multilingual (If yes, what languages)?
*
Your answer
Handedness
*
Left
Right
Mixed/Ambidextrous
With whom do you live?
*
Your answer
Name and phone number of closest relative or friend (Emergency Contact)
*
Your answer
Who referred you to NPI?
*
Your answer
Please describe the reason(s) you are seeking this evaluation. Please be as specific as possible.
*
Your answer
Check all concerns you have
*
Memory
ADHD
Autism/Aspergers
Anxiety
Depression
Behavior
Concussion
Organization
Dyslexia
Dysgraphia
Dyscalculia
Required
Is this evaluation in relation to any ongoing or upcoming lawsuit?
*
Yes
No
Is this evaluation the result of an auto or work-related incident?
*
Yes
No
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