NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
NAME
_____________________________
AGE
_____________________________
DATE OF BIRTH
_____________________________
SEX
_____________________________
ADDRESS
_____________________________
_____________________________
HOME PHONE
_____________________________
WORK PHONE
_____________________________
CELL PHONE
_____________________________
IF MINOR, NAME OF PARENT OR GUARDIAN
_____________________________
NAME OF REFERRING OR PRIMARY PHYSICIAN __________________________
ADDRESS OF REFERRING OR PRIMARY PHYSICIAN ________________________
_______________________________________________________________
TELEPHONE NUMBER OF REFERRING OR PRIMARY PHYSICIAN_______________
NAME OF INSURANCE COMPANY ___________________________
POLICY NUMBER ________________________________________
POLICY HOLDER
______________________________________
SECONDARY INSURANCE COMPANY _________________________
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
POLICY NUMBER ________________________________________
Neuropsychological and Psychological Sevices, P.C.
Intake Questionnaire
DATE OF BIRTH:
HISTORY OF PROBLEM:
Brief History of problem (include when began, surrounding circumstances,
treatment):
Ongoing symptoms (please check all that apply):
__ difficulty with problem solving
__ problems initiating
__ problems with planning or organizing
__ difficulty switching between tasks
__ difficulty doing more than one thing at a time
__ difficulty finding the right word
__ difficulty understanding what others are saying
__ difficulty writing
__ difficulty making sense of what you are reading
__ difficulty keeping track or recognition time
__ difficulty with reaction time
__ increased distractibility
__ problems concentrating
__ losing my train of thought
__ decreased alterness
__ forgetting where I leave things
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
__ forgetting events that have happened recently
__ problems learning new information
__ forgetting details from personal history
__ forgetting how to do things
__ tremors or shakiness
__ muscle weakness
__ problems with balance
__ difficulty holding onto things
__ problems with coordination
___ Other symptoms:
Please indicate if you have any difficulties in any of the following areas by
checking the function. If so, please describe what those issues are.
___ Self Care
___ Financial Management
___ Shopping
___ Time Management
___ Driving
___ Accessing or Utilizing Community Resources (e.g., church, library, support
groups, etc.)
___ Functional Mobility (e.g., getting around the house, getting around
outdoors)
___ Leisure and Recreation
___ Prevocational Skills (e.g., typing, writing, reading, etc.)
___ Medical Management (e.g., taking medications, scheduling/keeping doctor
appointments, etc.)
___ Socialization
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
___ Sexual Functioning.
EARLY DEVELOPMENTAL HISTORY
Place of Birth
Language you learned first
If other than English, when did you first begin to learn English
Any known problems with your birth or the surrounding pregnancy.
As a child, did you have any of these conditions or diagnoses? (check all that
apply)
___ attention problems
___ head injury
___hearing problems
___ hyperactivity
___ speech problems
___ vision problems
___ developmental delays ___ seizures
___ meningitis
___ encephalitis
___ oxygen deprivation
___ diabetes
___ asthma
___ heart problems
___ high fevers
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
___ other problems: _________________________________________________
At what age did you first
walk
talk
toilet train
MEDICAL HISTORY
Do you wear glasses? For what reason? __________________________________
Do you require a hearing aid? ___________
Are you color blind? ______________
PLEASE CHECK OFF ANY OF THE FOLLOWING MEDICAL PROBLEMS YOU MAY HAVE
EXPERIENCED IN THE PAST OR ARE CURRENTLY EXPERIENCING.
Now Past
___ ___
___ ___
___ ___
___ ___
Arthritis
Diabetes
Hypertension
Thyroid Disease
Now Past
___ ___
___
___
___
___
___
___
Meningitis
Kidney Disease
Heart Disease
Liver Disease
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
___
___
___
___
___
___
Parkinson’s Disease
Multiple Sclerosis
Seizure Disorder
___
___
___
___
Dementia
Stroke or TIA
Please list any other medical problems you may have experienced in the past or are currently
experiencing
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
PLEASE PROVIDE A LIST OF MEDICATIONS YOU ARE CURRENTLY TAKING
Type
Dose
When Started
Prescribing Physician
Problems
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
PSYCHIATRIC HISTORY
Please indicate if you have ever received any of the following diagnoses:
___ Depression
___ Bipolar Disorder
___ Psychosis
___ Obsessive Compulsive
___ Anxiety
___ Panic Disorder
___ Schizophrenia
___ Social Phobia
___ Please list any other psychiatric diagnosis or issue you have had
Please provide a list of any medications you are on for psychiatric reasons
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
Type
Dose
When Started
Prescribing Physician
_________________________________________________________
_________________________________________________________
_________________________________________________________
Problems
Please list all psychiatric hospitalizations you have had.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
SUBSTANCE ABUSE HISTORY:
Have you had any history of problems with alcohol of other substances?
___ Yes
___ No
Please identify what substances you have had problems with
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
At what age did you start ?
Please indicate what substances (including alcohol) you are currently using
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Do you consider this use a problem? ___ Yes ___No
FAMILY HISTORY
Please list all members of your family of origin, include any significant medical
or psychiatric problems they may have/had.
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
EDUCATIONAL HISTORY
At what age did you start school?
Did you experience any difficulty starting school? If so what kind of trouble
(e.g., emotional, learning, etc.)?
How many years of education did you attain? Your last degree
Subject/year
If dropped out of school please describe the surrounding circumstances.
Did you every repeat a class or grade?
Any special classes?
Diagnosis or assessments for learning problems/ADD?
VOCATIONAL HISTORY
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
Please list jobs you have held since finishing school, including any military duty.
Job
year started year stopped
general duties
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Please describe any unusual circumstances around leaving past jobs
Please indicate your current job
Company
Type of job/Title
Years of experience
Current hours per week
Job description
Current problems on the job
Military History (Please include rank, job duties, branch of service, discharge
date and type)
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
BEHAVIOR QUESTIONNAIRE
Please indicate if the behavior is a problem for you. If you answer yes, please rate the severity of the
problem (1 = mild, 4 = severe)
Anger; difficulty controlling temper
Yes
No
1
2
3
4
Impatient: upset when needs not easily met
Yes
No
1
2
3
4
Frequent complaining
4
Yes
No
1
2
3
Impulsivity; does things without thinking
Yes
No
1
2
3
4
Argumentative; often disputes topics
Yes
No
1
2
3
4
Lacks control over behavior; behavior
is inappropriate for social situations
Yes
No
1
2
3
4
Overly dependent; relies on others unnecessarily
does not do things for self.
Yes
No
1
2
3
4
Poor decision making; does not
think of consequences
Yes
No
1
2
3
4
Childish; at times behavior is immature
Yes
No
1
2
3
4
Poor insight; refuses to admit difficulties
Yes
No
1
2
3
4
Difficulty in becoming interested in things
Yes
No
1
2
3
4
Lack of initiative; does not thing for self
Yes
No
1
2
3
4
Irritable; snappy, grumpy
Yes
No
1
2
3
4
Sudden/rapid mood change
Yes
No
1
2
3
4
NEUROPSYCHOLOGICAL AND PSYCHOLOGICAL
SERVICES, P.C.
6120 BRANDON AVE. #315
SPRINGFIELD, VA. 22150
Alec A. Lebedun, Ph.D.
Telephone: (703) 866-0207
Fax: (703) 866-0208
e mail: alebedun@gmail.com
___________________________________________
NAME:______________________
Anxious; tense; uptight
Yes
No
1
2
3
4
Depressed; low mood
Yes
No
1
2
3
4
Irresponsible; can’t always be trusted
Yes
No
1
2
3
4
Overly sensitive; easily upset
Yes
No
1
2
3
4
Lacks motivation; lacks interest in doing things
Yes
No
1
2
3
4