Adult Evaluation Form - Sophia Robinson, Psy.D.

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Adult Evaluation Form

Name: (required)

Gender:

MaleFemale

Date:

Date of Birth:

Birthplace:

Age:

Address:

City, State, Zip:

Home Phone:

Cell Phone:

Work Phone:

May Dr. Robinson leave personal voice messages on one of your phones?

YesNo

If yes, which phone(s):

HomeCellWork

Do you consent to receiving text messages from Dr. Robinson?

YesNo

Do you consent to receiving emails from Dr. Robinson? YesNo

Email:

Health Plan Information:

Primary Plan:

Policy/Subscriber #:

Subscriber's Name:

D.O.B:

Soc. Sec. #:

Plan Ph#:

Claim Address:

Secondary Plan:

Policy/Subscriber #:

Subscriber's Name:

D.O.B:

Soc. Sec. #:

Plan Ph#:

Claim Address:

Emergency Contact Information:

Name:

Relationship:

Phone:

Referral Source:

Presenting Problems (be as specific as you can: describe problems, when did it start,...):

School History:

Currently in School? YesNo

Highest Grade / Degree:

Last/Current School Attended:

Average Grade Received:

Learning Strengths:

Specific Learning Disabilities:

Any behavioral problems in school?

What have teachers said about you?

Did you like school? YesNo

Comment:

Employment History:

Patient's Occupation:

Current Employer: (former. if no longer working):

Favorite Job(s):

Least Favorite Job(s):

Any work-related problems?

What would employers say about you?

Relationship and Family History:

Name of Spouse/Long term partner:

Length of Current Relationship:

Spouse/Partner Occupation:

Describe any stressors in current relationship:

List Past Marriages (start and end date, years together, names & statement about the nature of the relationship/s):

Children/Step Children (names/ages & brief statement on your relationship with the child/adult):

Siblings (name/age, if deceased: age and cause of death & brief statement about the relationship):

Biological Mother's History:

Living

Age

Deceased

Age

Cause of Death

If living, describe current relationship with her

Medical Problems:

Psychiatric Treatment:

Mother's drug / alcohol history:

Have any of your mother's blood relatives had any significant medical or psychiatric problems including drug or alcohol abuse/addiction, depression, anxiety, psychiatric hospitalization, suicide attempts?

Biological Father's History:

Living

Age

Deceased

Age

Cause of Death

If living, describe current relationship with her

Medical Problems:

Psychiatric Treatment:

Father's drug / alcohol history:

Have any of your father's blood relatives had any significant medical or psychiatric problems including drug or alcohol abuse/addiction, depression, anxiety, psychiatric hospitalization, suicide attempts?

Describe your childhood (Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems):

If Parents Divorced, Your Age at the Time:

How did their divorce affect you?

Medical History:

Primary Care Doctor (name /phone/city):

Other Medical Specialists (name/phone/condition they are treating):

Past and Present Medical Care (major medical problems, surgeries, injuries, illness):

Current Medications (Name, Dosage, Issue for which each medication is prescribed):

Past / Present Psychotherapy / Neurofeedback History (start-end date, approx. # of sessions,
helpfulness, name, city, ph# of therapist, reason treatment ended):

Psychiatric Hospitalizations (specify: month, year, number of days of each hospitalization, name of
hospital, reason for hospital):