When filling out this form, please be as specific as possible. Include dates and other detailed information where applicable.

By typing my initials in this box, I consent to sharing my personal medical and psychological history with Cognitive Solutions Learning Center, Inc. and its employees. I understand that all information will remain confidential, and not be shared with anyone outside of Cognitive Solutions Learning Center, Inc. without prior written consent:

Your Name:

Email:

Phone Number:

Date of birth:

Reason for requesting an assessment

Have you had a previous psychological or educational evaluation?

Please describe your current living situation:

Have you been to the doctor in the past year? If so, how is your current health? Are you being treated for anything?

Have you had both hearing and vision screenings in the past year? Please describe:

Please describe any medical or physical problems you have had:

Are you currently taking medication, either prescription or over the counter? If yes, carefully list the specific medication and dose date first prescribed, who prescribed, and for what purpose:

Please list any medications you have taken in the past, and the reason for the prescriptions:

Were there any problems or unusual circumstances during you mother's pregnancy or your delivery? If yes, please describe:

Were you adopted?

Were there any developmental problems including delay in learning to crawl, walk, or talk? If yes, please describe:

As a child, were you extremely physically active or always “on the go”?

Please provide a comprehensive school history, including name/type of schools attended as well as current school/grade level if applicable:

Please describe any of the following problems you have experienced, including the time of onset for each: Reading difficulty, writing difficulty, mathematics difficulty, poor grades, homework problems, peer problems, and/or organizational problems:

Please describe your greatest strengths and any special abilities or talents. What school subjects have you generally done best in?

What problems, if any, do you have with fears, tension, anxiety, panic attacks, phobias, being uncomfortable in new situations, or shyness? How has this changed over time?

What problems, if any, do you have with self-esteem? Are there particular things you are most likely to feel bad about?

Do you have any problems with sleep? If yes, please describe:

Please identify any blood relatives (i.e. "Dad's brother") who have or had learning or psychological difficulties of any kind:

Is there anything else it would be helpful to know about?